Group Health Insurance

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    GROUP HEALTH INSURANCE
     
     
     
     
    All benefits paid are per the schedule of benefits/summary plan document.
    **Listed premiums are employee’s monthly share. Rates are effective September 1, 2023.
     
    Plan C - High Deductible/Indemnity Plan - (Click here for Summary of Benefits and Coverage)
    Coverage                        Premium
    Single -                             $263.00
    Employee + Children -    $414.00
    Employee + Spouse -      $527.00
    Family -                             $629.00
     
    Deductible - $2,500 person / $5,000 family In-network
                           $5,000 person / $10,000 family Out-of-network
     
    Out-of-Pocket Limit - $6,500 person / $13,000 family In-network
                                         $13,000 person / $26,000 family Out-of-network
     
    Dr. Office Co-pays - $40/$75 employee co-pay for primary care and specialist visits, not subject to deductible/co-insurance, for network providers. If you see a non-network provider, the cost will be subject to Non-Network Deductible and Co-Insurance. 
     
    Prescription co-pays - employee/covered individual will pay $15 Generic/$45 Brand Name (Preferred) and $15 Generic/$85 Brand Name (Non-Preferred) or $250 (Specialty) for a 30 day supply, depending on the prescription.
     
    Plan D – Qualified High Deductible Health Plan with HSA - (Click here for Summary of Benefits and Coverage)
    Coverage                        Premium           Monthly HSA Contribution
    Single -                             $241.00                          $81
    Employee + Children -   $380.00                        $148
    Employee + Spouse -     $482.00                        $163
    Family -                            $577.00                         $208
     
    Deductible - $3,000 person / $6,000 family In-network
                           $5,400 person / $10,800 family Out-of-network
                           $3,000 In-network / $5,400 Out-of-network (Maximum amount that any one person will satisfy toward the annual family deductible)
     
    **Must complete HSA eligibility sheet with information regarding federal regulations and limitations.
     
    Out-of-Pocket Limit - $3,700 person / $7,400 family In-network
                                          $7,700 person / $15,400 family Out-of-network
                                          $3,700 In-network / $7,400 Out-of-network (Maximum amount that any one person will satisfy toward the annual family Out-of-pocket)
     
    Dr. office and prescription co-pays - WSBAIT will pay 100% of usual and customary charges after Deductible and Out-of-pocket limits are met. Prescription drugs and doctor office visits do not have co-pays. All charges are applied to deductible and out-of-pocket limits.
     
    Plan E – Qualified High Deductible Health Plan with HSA - (Click here for Summary of Benefits and Coverage)
    Coverage                        Premium           Monthly HSA Contribution
    Single -                              $187.00                         $94
    Employee + Children -    $294.00                        $170
    Employee + Spouse -      $373.00                        $187
    Family -                             $446.00                         $239
     
    Deductible - $5,000 person / $10,000 family In-network
                          $10,000 person / $20,000 family Out-of-network
                           $5,000 In-network / $10,000 Out-of-network (Maximum amount that any one person will satisfy toward the annual family deductible)
     
    **Must complete HSA eligibility sheet with information regarding federal regulations and limitations.
     
    Out-of-Pocket Limit - $5,500 person / $11,000 family In-network
                                          $12,000 person / $24,000 family Out-of-network
                                          $5,500 In-network / $12,000 Out-of-network (Maximum amount that any one person will satisfy toward the annual family Out-of-pocket)
     
    Dr. office and prescription co-pays - WSBAIT will pay 100% of usual and customary charges after Deductible and Out-of-pocket limits are met. Prescription drugs and doctor office visits do not have co-pays. All charges are applied to deductible and out-of-pocket limits.
     
    Plan G – Qualified High Deductible Health Plan with HSA - (Click here for Summary of Benefits and Coverage)  Available beginning July 1, 2023
    Coverage                        Premium           Monthly HSA Contribution
    Single -                              $120.00                         $94
    Employee + Children -    $267.00                        $170
    Employee + Spouse -      $340.00                        $187
    Family -                             $406.00                         $239
     
    Deductible - $6,500 person / $13,000 family In-network
                          $13,000 person / $26,000 family Out-of-network
                           $6,500 In-network / $13,000 Out-of-network (Maximum amount that any one person will satisfy toward the annual family deductible)
     
    **Must complete HSA eligibility sheet with information regarding federal regulations and limitations.
     
    Out-of-Pocket Limit - $6,500 person / $13,000 family In-network
                                          $14,300 person / $28,600 family Out-of-network
                                          $6,500 In-network / $14,300 Out-of-network (Maximum amount that any one person will satisfy toward the annual family Out-of-pocket)
     
    Dr. office and prescription co-pays - WSBAIT will pay 100% of usual and customary charges after Deductible and Out-of-pocket limits are met. Prescription drugs and doctor office visits do not have co-pays. All charges are applied to deductible and out-of-pocket limits.
     
    ANB Bank - New Account Application(Must fill out and take to ANB Bank)
    HSA Certification of Eligibility (Must fill out and return to Human Resources)
     
    Plans C, D, E and (G-July 1, 2023)
    -Preventive/Screening/Wellness visits are covered 100% prior to the deductible, subject to new Federal Requirements. (Examples)
    -Emergency room care - In-network deductible applies to Out-of-network benefits. **$250 penalty for non-emergency use**
    -All coverage is per the schedule of benefits & SPD.
     
    Filing Claims
    WSBAIT is the employee’s primary insurance carrier. All charges must be filed with WSBAIT prior to filing with a secondary carrier. (For dependents, refer to the Summary Plan Document.) If your provider does not file a claim for you, print the claim form below and submit to UMR. You must have a receipt from your provider that shows what they did, what you paid, and their tax ID #. You will need to add your name, ID# and our Group# (located on your insurance card) to your receipt. You may fax a copy to UMR, or mail a copy to:
     
    UMR
    Attn: Claims
    PO Box 8033, Wausau, WI 54402-8033 or FAX:  855-405-2189
     
     
    IRS Publication 502 (What is allowable for HSA expenses)
     
     
    TELADOC (Click here for more information) - Talk to a doctor anytime, 24 hrs, 7 days a week.
     

    UMR Network Providers - https://www.umr.com

    UMR MEDICAL Customer Service: 800-207-3172

    Prescriptions:

    OPTUMRx - optumrx.com

    **OPTUMRx Formulary Effective July 1, 2022** - (Click Here)

    **OPTUMRx Change/Exclusion List Effective July 1, 2022** - (Click Here)

    OPTUMRx Prior Authorization List July 1, 2022 - (Click Here)

    OPTUMRx Quantity List Effective July 1, 2022 - (Click Here)

    OptumRx (prescription) lines: 877-559-2955

    OPTUMRx  Mail Order Brochure - (Click Here)

     

     

    The COBRA cost to the individual is 102% of the full premium. An employee is covered under the Group Insurance Plan through the last day of the month employment terminates. Exception: Certified employees are covered through Aug. 31, if they work through the last day of school. Classified employees are covered through the month they last work as a regular employee.
    COBRA (continuation of coverage) is available when insurance benefits terminate for an employee and his/her dependents or if an employee and/or a dependent is no longer eligible.
    Related Links
     
     
      
    Please note: This website is intended for information only and is not a guarantee of benefits. We make the Summary Plan Descriptions readily available to all employees by posting them on this website, in a printable fashion to reduce paper waste of printing them. If you would like a printed copy, please feel free to print one yourself, or you may request one from the Benefits Specialist in HR. All benefits are subject to eligibility requirements and may change at any time. In the case of a difference between the above listed information and the master documents, the master documents will be controlling.