NA 4 Rates Local Deductible Plan PO4

User Manual: NA-4

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It’s Your Choice 2016
Local Deductible Plan (Revised 9/16/15)
Health Plan Name Medical with Dental Medical without Dental
Single Family Single Family
Anthem Blue Preferred Northeast 691.90 1,720.90 665.60 1,655.20
Anthem Blue Preferred Southeast 769.00 1,913.60 742.70 1,847.90
Arise Health Plan 1,011.80 2,520.60 985.50 2,454.90
Arise Health Plan - Aspirus Arise 968.60 2,412.60 942.30 2,346.90
Dean Health Insurance 713.30 1,774.40 687.0 0 1,708.70
Dean Health Insurance - Prevea360 691.20 1,719.10 664.90 1,653.40
GHC of Eau Claire 980.60 2,442.60 954.30 2,376.90
GHC of South Central Wisconsin 640.30 1,591.90 614.00 1,526.20
Gundersen Health Plan 775.00 1,928.60 748.70 1,862.90
Health Tradition Health Plan 681.90 1,695.90 655.60 1,630.20
HealthPartners Health Plan 873.90 2,175.9 0 8 47.6 0 2,110.20
Humana - Eastern 1,131.50 2,819.90 1,10 5.20 2,754.20
Humana - Western 1,182.0 0 2, 9 46.10 1,155.70 2,880.40
IYC Access Health Plan - Balance of State5 1,178.3 0 2,939.50 1,152.00 2,873.80
IYC Access Health Plan - Dane6 1,09 6.10 2,734.00 1,069.80 2,668.30
IYC Access Health Plan - Milwaukee7 1,270.60 3,170. 20 1,244.30 3,10 4. 50
IYC Access Health Plan - Waukesha8 1,178.30 2,939.50 1,152.0 0 2,873.80
IYC Medicare Plus4NA4NA4NA4NA4
Medical Associates Health Plans 644.30 1,601.90 618.00 1,536.20
MercyCare Health Plans 674.60 1,67 7.6 0 648.30 1,611.90
Network Health - Northeast 734.30 1,826.90 708.00 1,761.20
Network Health - Southeast 781.50 1,944.90 755.20 1,879.20
Physicians Plus 693.20 1,724.10 666.90 1,658.40
Security Health Plan 1,013.50 2,524.90 9 87. 20 2,459.20
State Maintenance Plan (SMP) 792.50 1,974.30 766.20 1,908.60
UnitedHealthcare of Wisconsin 870.00 2,16 6.10 843.70 2,100.40
Unity Health Insurance - Community 659.30 1,639.40 633.00 1,573.70
Unity Health Insurance - UW Health 605.60 1,505.10 579.30 1,439.40
WEA Trust - East 787.5 0 1,959.90 761.20 1,894.20
WEA Trust - Northwest Chippewa Valley 994.70 2,477.90 968.40 2,412.20
WEA Trust - Northwest Mayo Clinic Hlth. Sys. 994.70 2,477.90 968.40 2,412.20
WEA Trust - South Central 608.60 1,512.60 582.30 1,446.90
EMPLOYEE AND NON-MEDICARE RETIREE RATES
The employee and non-Medicare Retiree1 health plan rates on this page and Medicare Retiree Rates on the back of this sheet
reect total monthly premium rates for each health plan. See footnotes below and on the back of this sheet for more information.
NA = not applicable
1 Members of new participating employers may have a surcharge added to their rates. Your employer will inform you. Contact your
payroll ofce with questions.
2 Medicare 1 = Family coverage with at least one insured family member enrolled in Medicare Parts A, B and D.
3 Medicare 2 = Family coverage with all insured family members enrolled in Medicare Parts A, B and D.
4 Members with IYC Access Health Plan or SMP coverage who become enrolled in Medicare Parts A and B will automatically be moved
to the IYC Medicare Plus plan. All other non-Medicare family members remain covered under the IYC Access Health Plan or SMP.
Local Deductible Plan (Revised 9/16/15) It’s Your Choice 2016
Health Plan Name
Medical with Dental Medical without Dental
Single Medicare
12
Medicare
23
Single Medicare
12
Medicare
23
Anthem Blue Preferred Northeast 566.50 1,252.50 1,140.20 540.20 1,19 9. 9 0 1,074.50
Anthem Blue Preferred Southeast 605.10 1,368.20 1, 217. 4 0 578.80 1,315.60 1,151.70
Arise Health Plan 726.50 1,732.40 1,460.20 700.20 1,679.80 1,394.50
Arise Health Plan - Aspirus Arise 704.90 1, 6 6 7. 6 0 1,417.0 0 678.60 1,615.00 1,351.30
Dean Health Insurance 570.30 1, 277.70 1,147. 8 0 544.00 1,2 25.10 1,082.10
Dean Health Insurance - Prevea360 559.80 1, 245.10 1,126.80 533.50 1,192.5 0 1,061.10
GHC of Eau Claire 609.50 1,584.20 1,226.20 583.20 1,531.60 1,16 0.5 0
GHC of South Central Wisconsin 540.70 1,175.10 1,088.60 514.40 1,122.50 1,022.90
Gundersen Health Plan 498.70 1, 2 67.8 0 1,004.60 472.40 1,215.20 938.90
Health Tradition Health Plan 641.80 1,509.80 1,290.80 518.80 1,16 8.50 1,031.70
HealthPartners Health Plan 641.80 1,509.80 1,290.80 615.50 1, 457. 2 0 1, 225.10
Humana - Eastern 4 34.10 1,559.70 875.40 4 07.8 0 1, 5 07.10 809.70
Humana - Western 434.10 1,610.20 875.40 407.8 0 1, 5 57.6 0 809.70
NA4 1,6 5 9.10 NA4NA4 1,606.50 NA4
IYC Access Health Plan - Dane6NA4 1,576.90 NA4NA4 1,524.30 NA4
IYC Access Health Plan - Milwaukee7NA4 1,751.40 NA4NA4 1,698.80 NA4
IYC Access Health Plan - Waukesha8NA4 1,659.10 NA4NA4 1,606.50 NA4
IYC Medicare Plus4480.80 NA4 970.20 454.50 NA4 904.50
Medical Associates Health Plans 454.90 1,093.30 917.0 0 428.60 1,040.70 851.30
MercyCare Health Plans 536.30 1,205.00 1,079.80 510.00 1,152.40 1,014.10
Network Health - Northeast 5 87.70 1, 316.10 1,182.60 561.40 1,263.50 1,116.90
Network Health - Southeast 611.3 0 1,386.90 1,229.80 585.00 1,334.30 1,16 4.10
Physicians Plus 5 6 7. 2 0 1,254.50 1,141.60 540.90 1,201.90 1,075.90
Security Health Plan 616.80 1,624.40 1,240.80 590.50 1,571.80 1,175.10
State Maintenance Plan (SMP) NA4 1,273.30 NA4NA4 1,220.70 NA4
UnitedHealthcare of Wisconsin 634.60 1,498.70 1,276.40 608.30 1,4 46.10 1,210.70
Unity Health Insurance - Community 524.10 1,177.50 1,055.40 497.8 0 1,124.90 989.70
Unity Health Insurance - UW Health 499.90 1,099.60 1,007.00 473.60 1,0 47.0 0 941.30
WEA Trust - East 516.50 1, 2 98.10 1,040.20 490.20 1,245.50 974.50
WEA Trust - NW Chippewa Valley 589.10 1, 5 7 7. 9 0 1,185.40 562.80 1,525.30 1,119.70
WEA Trust - NW Mayo Clinic Hlth. Sys. 58 9.10 1, 57 7. 9 0 1,18 5.40 562.80 1,525.30 1,119.70
WEA Trust - South Central 453.90 1,056.60 915.00 427.6 0 1,004.00 849.30
MEDICARE RETIREE RATES
IYC Access Health Plan rates are determined by the employer county or the retiree county of residence. Counties are divided into the
following rate categories:
5 Balance of State: All other Wisconsin counties not listed below. (Code A4)
6 Dane: Dane, Grant, Jefferson, La Crosse, Polk and St. Croix. (A1)
7 Milwaukee: Milwaukee County. Also applies to retirees and continuants living out of state. (A2)
8 Waukesha: Kenosha, Ozaukee, Racine, Washington and Waukesha. (A3)
IYC Access Health Plan - Balance of State5

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