State Group Health Insurance
You are eligible to enroll in, make changes and cancel coverage for State Group Health insurance during the Annual Benefit Enrollment period from October 6 to October 31, 2014. Visit the Annual Benefit Enrollment (ABE) website for more information on upcoming changes and enrollment opportunities for 2015.
The University of Wisconsin offers comprehensive health insurance and prescription drug benefits to eligible employees and their family members. All plans offer hospital, surgical, medical and prescription coverage. The State Group Health Insurance Program is administered by the Department of Employee Trust Funds (ETF) and is available to University employees as well as State of Wisconsin employees.
Detailed plan information is provided in the It’s Your Choice: Decision & Reference Guides.
Benefit Plan Options
You may choose the health plan that will best meet the needs of you and your family. Employees have the choice between a Uniform Benefit plan or the Standard Plan. Uniform Benefit plans include HMO's and Regional PPO's that provide the same level of medical coverage, regardless of which plan you choose. Uniform Benefit plans have networks that are primarily in Wisconsin. The Standard Plan is a PPO with a nationwide network and is available in every county in WI.
See the Coverage and Plans and Providers tabs above for more information.
All healths plans offer a $150 incentive for the completion of a Health Risk Assessment (HRA) and a biometric screening per year. An HRA is a wellness survey that can be completed online or in some cases, in person. A biometric screening is a measurement of physical characteristics such as height, weight, body mass index, blood pressure and cholesterol. Your adult dependents are also eligible for the $150 incentive.
In addition, some plans offer other wellness benefits such as discounts on complimentary medicine, healthy living rewards and incentives. Contact your health plan or visit wellwisconsin.wi.gov for more information on wellness benefits.
You are eligible for the State Group Health Insurance plan if you:
- Have an Unclassified Faculty, Academic Staff, Limited or Classified appointment covered by the Wisconsin Retirement System.
- Have one of the following appointments and are expected to work at least 33% for one semester (academic year appointment) or 6 months (year-round appointment):
- Student Assistant (research assistant, fellow, scholar, trainee, TA/PA)
- Employee-in-Training (grad and post grad intern/trainee, postdoc fellow/trainee, intern, research associate).
- Have a Short Term Academic Staff appointment not covered under the Wisconsin Retirement System and you are expected to work:
- At least 21% for at least six months if you have an annual (12-month) contract; or
- At least 28% for at least one semester if you have an academic year (9-month) contract.
An eligible dependent includes:
- Domestic partner
- Your or your spouse’s or domestic partner’s unmarried or married children under age 26. Children remain eligible for coverage until the end of the month in which they are 26 years old.
- Your child may remain eligible beyond age 26 if he/she is incapable of self-support due to a physical or mental disability.
- If born to a covered child under age 18.
- Grandchildren remain eligible for coverage until the end of the month in which the grandchild’s parent turns 18.
For detailed information regarding dependent eligibility, see UWSA’s Dependent Eligibility Grid.
Eligibility to Continue Coverage when Employment Ends
You and your family members may be eligible to continue coverage when eligibility or employment ends. See Employment Changes for additional information.
EmployeeClassified employees may enroll within 30 days of employment begin date but you will be responsible for paying the entire premium.
- Permanent and project employees may enroll on or before the 1st of the month following the completion of 2 full months of WRS state/UW service and you will receive the employer contribution.
- Limited Term employees may enroll on or before the 1st of the month following the completion of 6 full months of WRS state/UW service and you will receive the employer contribution.
Unclassified Faculty, Academic Staff and Limited appointees, Student Assistants and Employees-in-Training may enroll within 30 days of employment begin date and will receive the employer contribution.
Coverage is effective on the first of the month on or following receipt of your application (provided all service requirements are met), either through eBenefits or paper application.
- You may enroll your dependents at the same time you enroll.
- You may add a spouse or domestic partner within 30 days of marriage or establishing a domestic partnership for benefit purposes (may add spouse’s or domestic partner’s children at same time).
- You may add a child within 60 days of gaining a child due to birth or adoption.
- You may add a spouse, domestic partner, or child within 30 days of their loss of coverage under a comparable group medical plan.
- If your family member does not have a Social Security number because he or she is not a United States citizen, you must submit an affidavit with your health insurance application to indicate your family member does not have a Social Security number.
Other Enrollment Opportunities
- May enroll during the Annual Benefit Enrollment period (occurs every fall) for coverage effective January 1st of the following year.
- May enroll within 30 days of a change in family status (e.g. marriage or domestic partnership), loss of other comparable group coverage or loss of employer contribution towards other comparable group coverage.
- May enroll within 60 days of the birth or adoption of a child.
- If you were initially eligible for coverage when you were not covered by the Wisconsin Retirement System (WRS), you may enroll within 30 days of your WRS coverage begin date.
- If you are not eligible for the full employer contribution towards your premium, you may enroll within 30 days of becoming eligible for the full employer contribution.
- You may enroll in the Standard Plan immediately prior to retirement (to preserve your sick leave credits).
The State Group Health Insurance Program offers coverage for hospital, surgical, medical, vision, dental and prescription coverage. You will have out-of-pocket expenses associated with each component of the plan until you reach your annual out-of-pocket maximum. Dental coverage does not have an annual out-of-pocket maximum.
Hospital, Surgical and Medical
Under all plans, most in-network services are subject to a 10% coinsurance. You will be required to pay 10% of the bill and your insurance will pay 90% of the bill. Once you reach your annual out-of-pocket maximum, services will be paid in full by your insurance*. Services considered to be preventative under federal guidelines are covered at 100%. See the Comparison of Benefits Chart to see what is covered under Uniform Benefits and the Standard Plan.
Annual Out-of Pocket Maximums
The annual out-of-pocket maximums for hospital, surgical and medical services received in-network are:
- All plans except Standard Plan: $500/person or $1,000/family
- Standard Plan: $800/person or $1,600/family
*Certain charges, such as the $75 Emergency Room co-pay, do not count towards in the annual out-of-pocket maximum.
To ensure that all members receive the same level of dental coverage through their health insurance, all health plans (except the Standard Plan and SMP) offer the same dental coverage. This is called Uniform Dental Benefits. Your health plan decides if you need to see certain dentists (in-network) to have benefits paid.
The Uniform Dental Benefit is included in your health insurance coverage at no additional cost to you. It is intended to provide coverage for diagnostic, preventive and restorative services (such as fillings). It does not include coverage for major dental services, such as crowns, root canals or implants. For a comparison between Uniform Dental Benefits and our two optional dental plans, EPIC Benefits+ and Dental Wisconsin, see our Dental Comparison Chart.
To learn more about Uniform Dental Benefits, read the Certificate of Coverage.
|In-Network Provider||Designated Out-of-Network Provider*||Covered Services (Examples)|
|Annual Benefit Maximum (per person)||$1,000||$1,000|
|Orthodontia (under 19)||50%||50%|
|Orthodontia Lifetime Maximum (per child)||$1,500||$1,500|
*A health plan may designate and authorize out-of-network providers so that at least one dentist is available in each county or major city, if applicable.
Benefit SummaryUniform Benefits
- An annual routine eye exam is covered for all members (subject to 10% coinsurance). Children under 5 years of age are covered at 100%.
- There is no coverage for eye glasses or contact lenses.
- Preferred Provider: For all members, an eye exam is covered for illness or disease (subject to plan deductible and 10% coinsurance). An annual routine eye exam is covered at 100% for children under 5 years of age.
- Non-Preferred Provider: Eye exam is covered for illness or disease only (subject to plan deductible and 10% coinsurance).
- There is no coverage for eye glasses or contact lenses.
Prescription drug coverage is automatically included in all health insurance plans at no additional cost, through Navitus Health Solutions, a nationwide pharmacy network.
You will be required to pay a co-payment when you buy prescription drugs. The amount you have to pay will be based on the co-payment level that applies to that prescription. Once you reach the applicable annual out-of-packet maximum, you will no longer have to pay the co-payment during that year.
Co-payments for 30-day supply of prescription:
- Level 1: $5 co-pay (formulary* generic and some low cost brand name drugs)
- Level 2: $15 co-pay (brand name and some high cost generic drugs)
- Level 3: $35 co-pay (non-formulary* drugs)
- Level 4: $50 co-pay (designated specialty drugs - see below)
*What is a Formulary? A prescription drug formulary is a list of prescription drugs established by a committee of physicians and pharmacists, which are determined to be medically and cost effective. Each drug is assigned a level, which determines the co-payment for that drug. Navitus may require prior authorization for certain formulary and non-formulary drugs before coverage applies. These drugs are shown on the formulary with “PA”. You must log in to Navitus to review the formulary.
Annual Out-of Pocket Maximums
- Level 1 and 2 drugs (all plans except Standard Plan): $410/person or $820/family
- Level 1 and 2 drugs (Standard Plan): $1,000/person or $2,000/family
- Level 3 drugs: no out-of-pocket maximum
- Level 4 drugs for all plans: $1,000/person or $2,000/family
Prescription Cost Savings / Mail Order
If you order your prescriptions by mail, you may reduce your out-of-pocket prescription costs:
- If you order through WellDyneRx, you will receive up to a 90 day supply of Level 1 and Level 2 drugs for the price of a 60-day supply.
- If you order through Diplomat Specialty Pharmacy you will receive Level 4 drugs at a $15 co-pay instead of a $50 co-pay.
Please contact WellDyneRx or Diplomat Specialty Pharmacy to start mail order.
Some high-cost prescription medications have been designated as Specialty Drugs on the formulary. A $50, Level 4 copayment applies to covered, formulary, and non-formulary prescription drugs classified as specialty medications. A reduced, $15 copayment applies when a covered, formulary specialty medication is filled at Diplomat Specialty Pharmacy.
If you are on a specialty medication, the Navitus SpecialtyRx Program is offered through a partnership with Diplomat Specialty Pharmacy to help coordinate members’ specialty pharmacy needs. Prescriptions for formulary specialty medications, marked with “ESP” in the formulary, that are filled at Diplomat receive a reduced $15 copayment. The reduced copayment does not apply to covered, non-formulary specialty medications.
To begin receiving your self-injectable and other specialty medications from the specialty pharmacy, please call
Navitus SpecialtyRx Customer Care at (877) 651-4943 or visit diplomatpharmacy.com.
To see if a drug is on the Specialty Drug list, the most up-to-date formulary information is available on the Navitus website through Navi-Gate for Members. Under Quick Links, click on Members – Your Formulary to log in and then select the formulary named State of WI and WI Public Employers Formulary. You can also call Navitus Customer Care toll-free at 866-333-2757 with Specialty Drug questions.
|Specialty Drug Formulary||Member Cost Per 30-day Supply||Annual Out-of-Pocket Maximum||Category||Mail Order Available|
|Level 4||$50 copay||$1,000 per person/
$2,000 per family
|High cost non-formulary and Self-Injectibles and Specialty Drugs||Diplomat Specialty Pharmacy – Copay for Formulary Specialty Drugs reduced to $15/month|
Plans and Providers
Selecting a Plan
When you enroll, most plans require you to choose a primary care physician (PCP) or a primary clinic for you and your family members. If you need specialty care, your doctor will coordinate your care.
You should consider the following factors when you select a health plan:
- Type of plan you want – HMO, Regional PPO, or Nationwide PPO based on plans available in your area
- Provider network / access to physicians or other health care providers
- Referral policies
- Dental benefits and providers
- Other perks (e.g. healthy living rewards, incentives, complementary medicine)
Use the Health Plans by County Tool to determine what plans are available in your county.
- All HMO plans are in the lowest cost employee premium tier.
- Use a specific network of doctors, clinics, hospitals, and other medical providers located in a specific geographic area.
- Expected to receive services within the network.
- Services covered out-of-network only in emergency situation or upon approved referral.
- Provide dental benefits (except SMP).
PPOs with Regional Network - All WEA Trust Plans and WPS Metro Choice Southeast & Northwest
- All plans, except WPS Metro Choice Southeast, are in the lowest cost employee premium tier.
- Provide same level of benefits as the HMOs when services are in-network.
- Services available out-of-network with higher out-of-pocket cost.
- Provide dental benefits.
PPO with National Network – Standard Plan
- In highest cost employee premium tier.
- Self-funded; administered by Wisconsin Physicians Service (WPS).
- Nationwide provider network.
- May see the medical provider of your choice.
- Lower out-of-pocket costs if you use Standard Plan PPO in-network provider.
- No dental benefits.
Forms and Publications
- Application - Complete and submit to your institution’s benefits office to enroll in the plan. Watch ETF's presentation on how to properly complete each section of the application.
- Affidavit for Insurance Purposes – Dependent Lacks Social Security Number due to Non-Citizenship - Complete and submit with your health insurance application if your covered family member is not a United States citizen and does not have a Social Security number.