After DEDUCTIBLE, subject to copays below, to OOPL. See Note, below, for exceptions on preventive prescription drugs. Under no circumstances will YOU pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,850 single / $13,700 family for federally required essential health benefits. 1 Level 3 prescription drug COINSURANCE will continue to be paid by YOU past the OOPL, to the federal MOOP, see more information below. 2Federally required preventive services are covered at 100%. 3 State of Wisconsin MEDICARE eligible annuitants and their MEDICARE eligible dependents are limited to participation under the MEDICARE Prime Uniform Benefits SCHEDULE OF BENEFITS. Benefit: WPE eligible WPE eligible WPE eligible High Participating PARTICIPANTS PARTICIPANTS PARTICIPANTS DEDUCTIBLE Wisconsin Public in (Program in PO 6 who are in PO 4 including Health Plan WPE Option PO 2 and not eligible for MEDICARE eligible (PO 7) Employer’s (WPE) MEDICARE nor enrolled in eligible and PARTICIPANTS 3 eligible and MEDICARE as enrolled enrolled in PO 6 the primary and PO 7) payor3 Annual Medical None $250 $500 Individual/ The DEDUCTIBLE must be met before DEDUCTIBLE Individual/$500 $1,000 Family coverage begins. applies to Family The DEDUCTIBLES When an $1,500 per are: (OOPL). When an individual within a individual plan individual within a family plan meets $3,000 per family family plan meets the $500 plan. the $250 DEDUCTIBLE, DEDUCTIBLE DEDUCTIBLE, COINSURANCE includes COINSURANCE will apply to prescription drugs. will apply to covered medical covered medical services. services. Medical Medical DEDUCTIBLE DEDUCTIBLE does not apply to does not apply to prescription drugs. office visit COPAYMENTS or prescription drugs.
After DEDUCTIBLE, subject to copays below, to OOPL. See Note, below, for exceptions on preventive prescription drugs. Under no circumstances will YOU pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,850 single / $13,700 family for federally required essential health benefits. 1 Level 3 prescription drug COINSURANCE will continue to be paid by YOU past the OOPL, to the federal MOOP, see more information below. 2Federally required preventive services are covered at 100%. 3 State of Wisconsin MEDICARE eligible annuitants and their MEDICARE eligible dependents are limited to participation under the MEDICARE Prime Uniform Benefits SCHEDULE OF BENEFITS. Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Annual Medical DEDUCTIBLE applies to (OOPL). None $250 Individual/$500 Family When an individual within a family plan meets the $250 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to office visit COPAYMENTS or prescription drugs. $500 Individual/ $1,000 Family When an individual within a family plan meets the $500 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to prescription drugs. The DEDUCTIBLE must be met before coverage begins. The DEDUCTIBLES are: $1,500 per individual plan $3,000 per family plan. DEDUCTIBLE includes prescription drugs.
Exhibit1_PBP_Agreement_Rev.docx