The University of Wisconsin offers comprehensive medical and prescription drug coverage to eligible employees and their family members through the State Group Health Insurance Program. This program is administered by the Department of Employee Trust Funds (ETF) and is offered to all eligible State of Wisconsin employees. Employees who elect participating in the State Group Health Insurance Program are also given the option to participate in Uniform Dental.
See the 2016 Health Insurance Information on the Department of ETF website for details.
Benefit Plan Options
You may choose the health insurance plan option that will best meet the needs of you and your family. If you do not elect health insurance, you may be eligible for an Opt-Out incentive. See the Opt-Out tab for more information.
Employees have the choice between:
- It’s Your Choice (IYC) Health Plan (formerly Coinsurance Uniform Benefits) or Access Plan (formerly the Standard Plan)
- In addition, both plan options offer a high deductible health plan (HDHP) option which has a higher deductible in exchange for a lower monthly premium. Enrollment into the HDHP option requires you to enroll in a Health Savings Account (HSA). The UW will contribute to your HSA.
- Electing a health plan with or without Uniform Dental. See Coverage tab for more information.
IYC Health Plan
(formerly Coinsurance Uniform Benefits)
(formerly Standard Plan)
Overall, there are four plan options to choose from:
See the Coverage and HDHP/HSA tabs above for more information.
All health 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. You and your spouse/domestic partner are both eligible for the $150 incentive. Wellness incentives are taxable as wages.
In addition, some plans offer other wellness benefits such as discounts on complementary medicine, healthy living rewards and incentives. Contact your health plan or visit wellwisconsin.wi.gov for more information on wellness benefits.
The HDHP and HSA plans are mutually exclusive. If you enroll in an HDHP, you must also enroll in the HSA.
Note: There are special eligibility requirements that need to be met in order to enroll in this plan. See below for eligibility details.
What is a High Deductible Health Plan (HDHP)?
It is a health plan that, under federal law, has a minimum annual deductible and a maximum annual out-of-pocket limit set by the IRS. An HDHP does not pay any health care costs until the annual deductible has been met (with the exception of preventive services and prescriptions mandated by the Patient Protection and Affordable Care Act). After the annual deductible has been met, you will be responsible for office visit copays and applicable coinsurance (generally 10%) on non-office visit services, up to the maximum annual out-of-pocket limit. The plan is designed to offer a lower monthly premium in return for more shared health care costs by the member.
The 2016 limits are shown below:
Annual HDHP Limits
All employees covered under by the Wisconsin Retirement System (WRS) are eligible to enroll in the HDHP (High Deductible Health Plan or Access HDHP) unless one of the following applies:
- The employee or any covered dependents are enrolled in Medicare, TRICARE, or another health plan that is not considered an HDHP; or
- The employee or any covered dependents enroll in the Healthcare Flexible Spending Account (FSA) plan for 2016 or carry over any remaining Healthcare FSA funds from 2015 into 2016; or
- The employee is a dependent of another person for tax purposes; or
- The employee is eligible for the Short-Term Academic Staff/Graduate Assistant benefits program.
What is a Health Savings Account (HSA)?
Employees who elect the HDHP are also required to establish a state-sponsored Health Savings Account (HSA). A Health Savings Account (HSA) is a pre-tax savings account used to pay for eligible medical, dental, prescription and vision expenses (similar to the Healthcare Flexible Spending Account). You may make tax-free contributions through payroll deduction, subject to annual limits. The UW will contribute to the account and employees have the option of contributing up to the annual maximum limit.
The HSA is administered by TASC.
The 2016 limits are shown below:
|Employee||$3,350 (includes UW contribution)||$6,750 (includes UW contribution)|
In order to be eligible for an HSA, you must be eligible for and enrolled in an HDHP.
|You must meet the following requirements to be eligible for this plan:
||An eligible dependent includes:
Additional eligibility requirements apply to the High Deductible Health Plan (HDHP) options. See the HDHP/HSA tab above.
For detailed information regarding dependent eligibility, see UWSA’s.
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.
University Staff (formerly Classified employees)– University Staff, University Staff Project and WRS-eligible University Staff Temporary employees choose the effective date of coverage for health insurance. Coverage will be effective:
- As soon as possible. This will be the first of the month on or after your WRS eligibility date. You will pay the full cost for the first two months of coverage; OR
- When the employer contributes to premiums. This will be the first of the month on or after you have completed 2 full months of WRS State/UW service. You will receive the employer contribution with the first month of coverage.
If using the application, ET-2301, check the box in Section 4 that elects indicates if you want coverage to be effective as soon as possible or when the employer contributes to premiums.
Sample of Section 4 of ET-2301
Faculty, Academic Staff and Limited appointees, Student Assistants and Employees-in-Training may enroll within 30 days of hire date and will receive the employer contribution.
- Coverage will be effective the first of the month on or following the date of hire if the application is received by your employer, either via eBenefits or paper application, within 30 days of hire.
- 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 involuntary 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 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), involuntary 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 Access Plan (formerly 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 limit. Dental coverage does not have an annual out-of-pocket limit. See the Comparison of Medical Benefits Chart for more information.
State Group Health Insurance offers different medical plan designs. Individuals may select either an IYC Health Plan for a regional network or an Access plan for a nationwide network. Both plan designs will offer the option to enroll in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) option for eligible employees.
Most in-network medical services are subject to a deductible and either an office visit copayment or 10% coinsurance. Once you reach your annual out-of-pocket limit, services will be paid in full by your insurance (with limited exceptions such as emergency room copayments, Level 3 prescriptions, etc.) for the remainder of the calendar year. Services considered to be preventive under federal guidelines are covered at 100%.
You have some basic decisions to make about your health insurance enrollment. All of the offered health plans, except the Access Plan, offer the same Uniform Benefits coverage. You are primarily choosing:
- The type of plan you want-- HMO, Regional PPO, Nationwide PPO or HDHP, based on the plans available in your area
- Provider network/ access to physicians, hospitals or other health care providers
- Cost-- including deductible, out-of-pocket medical costs and monthly premium costs, deductible and level of employee premium contributions.
- Plan performance on quality measures
- Other wellness benefits or perks (e.g. healthy living rewards, incentives, complementary medicine)
Where Do I Start?
Do you want to enroll for health insurance?
You must complete a health insurance application, even if you choose to Opt-Out of coverage.
Waive-- declining coverage
Opt-Out-- declining coverage and eligible for the Opt-Out Incentive
|If you waive coverage and are not covered as a dependent under a State of Wisconsin Health Insurance program, you may be eligible for an annual Opt-Out incentive of up to $2,000.|
Do you want to enroll for a High Deductible Health Plan (HDHP)?
Regular Health Plan
|The HDHP plan options offer lower employee premiums but have higher annual deductibles and out-of-pocket limits. You must also open an HSA.|
Do you have a need to access providers nationwide? Emergency care is covered wherever you are.
See Health Plan Map for health plans in your area.
If yes, consider electing the Access Plan or Access HDHP. These plan options have higher employee premiums but offer a nationwide PPO network. The other health insurance plan options have regional provider networks.
Most employees select the IYC Health Plan or IYC HDHP.
Do you want basic dental coverage (Uniform Dental)?
|Basic dental coverage is included with your health insurance unless you waive the coverage. The dental coverage is called Uniform Dental and is provided by Delta Dental of Wisconsin. You can also elect supplemental dental coverage through other employee-pay-all plans.|
To ensure that all members are eligible to receive the same level of basic dental coverage through their health insurance, all health plans offer the same option for dental coverage. This is called Uniform Dental and is administered by Delta Dental of Wisconsin. You have the option of electing participation in a health insurance plan with or without Uniform Dental included. If you do not elect a plan that includes Uniform Dental, your monthly premium will be reduced.
Uniform Dental provides 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 and our two optional dental plans, EPIC Benefits+ and Dental Wisconsin, see the.
Covered Services (Examples)
|Annual Benefit Maximum|
|Diagnostic / |
|Periodontal||80%||Periodontal Maintenance Only|
Maximum (per child)
- An annual routine eye exam is covered for all members (subject to a $25 copayment). Children under 5 years of age are covered at 100%.
- There is no coverage for eye glasses or contact lenses.
Access Plan (formerly the Standard Plan)
- Preferred Provider: For all members, an eye exam is covered for illness or disease (subject to plan deductible and $25 copayment). Children under 5 years of age are covered at 100%.
- Non-Preferred Provider: Eye exam is covered for illness or disease only (subject to plan deductible and10% 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 copayment or coinsurance when you buy prescription drugs. The amount you have to pay will be based on the copayment or coinsurance level that applies to that prescription. Once you reach the annual out-of-pocket limit, if applicable, you will no longer have to pay the copayment during that year.
*HDHP Enrollees: You will be responsible for the full cost of prescriptions (with the exception of certain preventive drugs) until you have met your annual deductible. Once you meet your annual deductible, the payment structure below will apply.
See the Pharmacy Benefit Plan Comparison for more information.
Out-of-pocket costs for 30-day supply of prescription:
- Level 1: $5 copay (formulary* generic and some low cost brand name drugs)
- Level 2: 20% coinsurance, up to $50 (brand name and some high cost generic drugs)
- Level 3: 40% coinsurance, up to $150 (non-formulary* drugs)
- Level 4: $50 copay (if using the Specialty Pharmacy for Preferred Drug - see below) or 40% coinsurance, up to $200.
Note: Diabetic supplies and glucometers are covered with a 20% coinsurance. In most cases this coinsurance applies to your prescription drug out-of-pocket limit.
*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 necessary 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 Limits
2016 Member Pharmacy Benefit Costs
|Formulary Level||Member Costs||Member Out-of-pocket Limit|
|Level 1||$5||Level 1 & 2 combined: $600 single/ $1,200 family|
|Level 2||20% ($50 max)|
|Level 3||40% ($150 max)||Does not apply toward out-of-pocket limits (Federal maximum out-of-pocket limit applies.)|
|Level 4||Preferred||$50¹ or 40% ($200 max)||$1,200 single/ $2,400 family|
|Non- Preferred||40% ($200 max)||Does not apply toward out-of-pocket limits (Federal maximum out-of-pocket limit applies.)|
¹ Reduced copay of $50 applies only when Preferred Specialty Drugs are obtained from a Preferred Specialty Pharmacy.
*HDHP Enrollees:You will be responsible for the full cost of prescriptions (with the exception of certain preventive drugs) until you have met your annual deductible. Once you meet your annual deductible, the payment structure above will apply, up to your out-of-pocket limit.
Prescription Cost Savings / Mail Order
By ordering 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 $50 copay instead of a 40% coinsurance, up to a limit of $200 per fill.
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 40% coinsurance up to $200 per fill applies to covered, formulary, and non-formulary Level 4 prescription drugs classified as specialty medications. A reduced, $50 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 $50 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.
Summary of Specialty Drugs Cost
|Specialty Drug Formulary||Member Cost per 30-day SUpply||Annual Out-of-Pocket Limit||Category||Mail Order Available|
|Level 4||40% coinsurance, up to $200||$1,200 per person/ $2,400 per family||High cost non-formulary and Self-injectibles and Specialty Drugs||Diplomat Specialty Pharmacy-- Copay for Formulary Specialty Drugs reduced to $50/month|
Health Insurance Opt-Out Incentive
You may be eligible to receive up to a $2,000 Opt-Out Incentive from the UW if you Opt-Out (waive coverage) of State Group Health Insurance coverage. The maximum annual Opt-Out Incentive is $2,000 for single or family coverage.
The $2,000 Opt-Out Incentive is pro-rated. You will receive an equal portion of the payment in each payroll period (for bi-weekly employees, payment will be made in the first two payrolls of the month).
Crafts workers, University Staff Temporary employees, Student Assistants (fellows, scholars and trainees and Employees-in-Training (grad intern/trainee, post doc fellow/trainee) are not eligible for the Health Insurance Opt-Out Incentive.
State law prohibits eligible employees who opted-out of the State Group Health Insurance coverage in 2015 to be eligible for the Opt-Out incentive.
If you are considering opting-out of health insurance coverage, it is important to know the following:
- Impact on Sick Leave Credits. Unused sick leave can provide a valuable benefit. When you retire, or if you should die while an employee, unused sick leave is converted into credits to pay for health insurance for you or your surviving spouse/domestic partner/dependents but only if you are covered under the State Health Insurance program. If you choose to Opt-Out, your unused sick leave credits have no value until/unless you re-enroll in the future.
- Re-enrolling in health insurance. You may re-enroll during the year if you have a qualifying event (such as marriage, birth of a child, loss of other coverage). The $2,000 Opt-Out Incentive will be pro-rated by payroll period and you will lose any portion that is payable after you have re-enrolled.
- Enrollment in Other Benefit Plans. If you Opt-Out of health insurance, you are also opting out of Uniform Dental. However, you may still elect the supplemental dental plans, Dental Wisconsin and/or EPIC Benefits+ and/or the supplemental vision plan, VSP.
- Taxes. The $2,000 is taxable.
- Affordable Care Act (ACA). The ACA requires most Americans to have health insurance or pay an annual penalty. If you Opt-Out of this health insurance program and do not have coverage through a spouse or parent, you may be subject to a fine when you file your federal income taxes.
How to Opt-Out
You must complete a paper health insurance application, form ET-2301, and submit the form to your institution’s benefits office within 30 days of your eligibility date. If your institution allows eBenefits enrollment, you must still complete a paper application. Do not take any action for health insurance via eBenefits.
You only need to complete the following sections of the health insurance application, form ET-2301:
- At the top of the form, check “Yes” in the box that says “I am electing to opt out of health insurance for 2016.”
- Complete Sections 1 (Employee Information) and 2 (Spouse/Domestic Partner information).
- Section 2 must be completed even if the spouse/domestic partner is not covered under the State Group Health Insurance program.
- Sign and date Section 6.
If you are unsure whether you are eligible to Opt-Out and receive the $2,000 incentive, please contact your institution’s benefits office for assistance.