Group Health Insurance

Plans C, D, E and G

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.

UMR MEDICAL Customer Service

800-207-3172

Plan C - High Deductible/Indemnity Plan

Coverage	Premium
Single	$267.00
Employee + Children	$421.00
Employee + Spouse	$536.00
Family	$639.00

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

Coverage/Premium	Monthly HSA Contribution
Single - $245.00	$86
Employee + Children - $386.00	$153
Employee + Spouse - $490.00	$168
Family - $586.00	$213

Deductible

$3,200 person / $6,400 family In-network
$5,600 person / $11,200 family Out-of-network
$3,200 In-network / $5,600 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

$3,900 person / $7,800 family In-network
$7,900 person / $15,800 family Out-of-network
$3,900 In-network / $7,900 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

Coverage/Premium	Monthly HSA Contribution
Single - $190.00	$99
Employee + Children - $299.00	$175
Employee + Spouse - $379.00	$192
Family - $453.00	$244

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

Coverage/Premium	Monthly HSA Contribution
Single - $120.00	$99
Employee + Children - $272.00	$175
Employee + Spouse - $345.00	$192
Family - $412.00	$244

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.

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

UMR Claim Form

IRS Publication 502
What is allowable for HSA expenses

New this year, employees on the district's health insurance also receive access to ReviveHealth, a membership program that provides virtual primary care, urgent care and mental health therapy at no extra cost.

More than 1,000 medications are included and available through ReviveHealth for free.

ReviveHealth

ReviveHealth Details

Medications List

Prescription Benefits

UMR Network Providers
UMR Medical Customer Service: 1-800-207-3172
Prescriptions: 1-877-559-2955
OPTUMRx
**OPTUMRx Standard Formulary Effective January 1, 2025
**OPTUMRx Premium Formulary Exclusions and Preferred Specialty Prior Authorization Requirements January 1, 2025
OPTUMRx Preventive Care Medications January 1, 2025
OPTUMRx Mail Order Brochure

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.

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.

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In this section

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Group Health Insurance

WSBAIT Summary Plan Document

Plan C - High Deductible/Indemnity Plan

Plan D – Qualified High Deductible Health Plan with HSA

Plan E - Qualified High Deductible Health Plan with HSA

Plan G – Qualified High Deductible Health Plan with HSA

Filing Claims

Contact Us

Quicklinks