Plan Summary

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. See the 2015 Health Insurance information on the Department of Employee Trust Funds website for details.

Each health plan offers a High Deductible Health Plan option.  If enrolled in a High Deductible Health Plan, you are required to enroll in a Health Savings Account.  See the 2015 HDHP/HSA information on the Department of Employee Trust Funds website for details.

Detailed plan information is provided in the State Group Health It's Your Choice Decision Guide.

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.

Both plans 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.

See the Coverage and Plans and Providers tabs above for more information.

Wellness Benefits

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. 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 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:

  • Spouse
  • Domestic partner
  • Children
    • Your, 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.
  • Grandchildren
    • 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.



Classified employees may enroll within 30 days of employment begin date but 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 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 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 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 for Insurance Purposes 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. See the Out-of-Pocket Expenses Chart for more information.

Benefit Summary

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.

Benefit Summary

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 Dental Benefits Certificate of Coverage.

Summary of Uniform Dental Benefits
Out-of-Network Provider*
Covered Services (Examples)
Annual Benefit Maximum
(per person)
Diagnostic /
100%50%Routine Evaluations
Fluoride Treatments
Periodontal80%50%Periodontal Maintenance Only
80%50%Local Anesthesia
(under 19)
Orthodontia Lifetime
Maximum (per child)

*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 Summary
Uniform 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.
Standard Plan
  • 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.

There is also additional vision coverage offered under our three optional plans: Dental Wisconsin, EPIC Benefits+ and VSP Vision.

Prescription drug coverage is automatically included in all health insurance plans at no additional cost, through Navitus Health Solutions, a nationwide pharmacy network.

Benefit Summary

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.

*HDHP Enrollees: You will be responsible for the full cost of prescriptions until you have met your annual deductible. Once you meet your annual deductible, the co-payments below will apply.

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 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 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.

Specialty Drugs

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

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
Member Cost
Per 30-day
Annual Out-of-
CategoryMail Order Available
Level 4$50 copay$1,000 per
person /
$2,000 per
High cost non-formulary
and Self-Injectibles and
Specialty Drugs
Diplomat Specialty
Pharmacy – Copay for
Formulary Specialty Drugs
reduced to $15/month


Plans & 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, Nationwide PPO or HDHP based on plans available in your area
  • Provider network / access to physicians or other health care providers
  • Cost
  • Quality
  • Referral policies
  • Dental benefits and providers
  • Other perks (e.g. healthy living rewards, incentives, complementary medicine)

Use the Health Plan Map to determine what plans are available in your county.

See the Health Plan Descriptions for information about each plan. See ETF’s website for the phone number and website of each health plan.


  • 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.

High-Deductible Health Plan (HDHP)

  • Lower employee premium rates in exchange for increased employee cost sharing.
  • May select any HMO or PPO plans.
  • Annual deductible is $1,500 for Single coverage or $3,000 for Family coverage.
    • Health plan does not pay any health, dental or prescription costs until the annual deductible is met (with the exception of federally mandated preventive services).
    • After the deductible is met, all HDHPs will provide a uniform set of benefits
  • If you enroll in an HDHP, you must enroll in a Health Savings Account (HSA)
  • If you enroll in an HDHP and an HSA, you are also eligible to enroll in a Limited Purpose Flexible Spending Account (LPFSA). See the Flexible Spending webpage for more information.
  • Eligibility: All employees covered by the Wisconsin Retirement System (WRS) are eligible to enroll in the 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, or is covered under someone else’s FSA plan; or
    • The employee is a dependent of another person for tax purposes; or
    • The employee is eligible for the Graduate Assistant/Short-Term Academic Staff benefits program.


UW System State Group Health Monthly Employee Premium – 2015
Tier Employees Covered by WRS – Regular Employees Covered by WRS – HDHP Employees Covered by Graduate Assistant / Short-term Academic Staff (Regular only)
Single Family Single Family Single Family
Tier 1 $92.00 $230.00 $32.00 $81.00 $46.00 $115.00
Tier 2 (Standard Plan – required to work out of state) $136.00 $341.00 $76.00 $192.00 $68.00 $170.50
Tier 3 (Standard Plan) $267.00 $666.00 $207.00 $517.00 $133.50 $333.00

WRS covered employees who are working less than 50% and Classified LTE’s with one appointment pay 50% of the total premium.

Total monthly health insurance premiums for each plan (shows the combined employee and employer premium contributions).

Forms & 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 (UWS 93) – 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.
  • COBRA NOTICE 2015 September 9, 2015 202.6 KiB