Medical Insurance and Pharmacy

On this page:

• Medical Plans
• Prescription Drug Coverage
• Definitions
• Sydney App
• Omada Wellness Programs
• Tobacco Cessation Program
• Preview for Plan Year 2025 Regarding Spouses
• Qualifying Life Events

 

Medical Plans

Wright State provides comprehensive medical and pharmacy coverage to employees appointed to work at or above a 75% full-time equivalency basis and their eligible dependents. 

Having access to high-quality, comprehensive medical plans is important. Wright State offers three medical plans through Anthem Blue Cross Blue Shield, two copay-based plans, and one High Deductible Health Plan (HDHP), so you can choose the plan that works best for you. All plans cover in-network preventive care at no cost to you, as well as prescription drug benefits and mental health services. Your 2024 medical plan options are described below.

Blue High-Performance Network

A copay-based plan that requires you to receive medical care from a specific network of providers in Ohio, Kentucky, and Indiana. Out-of-network services are not covered under this plan, except for emergencies. The plan has lower employee premiums and copays when obtaining services, as well as a lower total cost for both employees and Wright State University.

High Deductible Health Plan

This plan offers both in and out-of-network coverage. Services are subject to a deductible and coinsurance up to the out-of-pocket maximum. When in-network services are received, your deductible and coinsurance amounts are lower than when services are obtained outside of the network. The plan has the second lowest employee premiums, and Wright State’s annual contribution to the Health Savings Account remains unchanged from last year ($500 for employee-only coverage and $1,000 for all other coverages). 

PPO 80/20 Plan

A copay-based plan that offers both in and out-of-network coverage. Certain services require a copay, and others are subject the deductible and coinsurance up to the out-of-pocket maximum. When in-network services are received, your deductible and coinsurance amounts are lower than when services are obtained outside of the network.

Prescription Drug Coverage

All university-sponsored medical plans include prescription drug coverage. The Essential Drug List - 4 Tier Drug Plan (PDF) is the university’s list of generic, brand and specialty drugs that are covered by the plan.

• Tier 1 drugs have the lowest cost share.
• Tier 2 drugs have a higher cost share than Tier 1.
• Tier 3 drugs have a higher cost share and may include drugs that were recently approved by the Food and Drug Administration (FDA).
• Tier 4 drugs have the highest cost share and usually include specialty brand drugs. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and may need special handling.

Prescriptions can be filled at any in-network retail pharmacy, including CVS, Walmart, Kroger, Sam’s Club, Costco, Dayton Children’s Hospital, etc. Walgreens pharmacy is not in-network.

Anyone taking long-term maintenance prescriptions on the Maintenance Drug List (PDF), such as those for heart disease, high blood pressure, etc., is required to fill these prescriptions in 90-day quantities from an Rx Maintenance 90 Pharmacy Network (PDF) or by mail through Anthem’s mail service pharmacy, CarelonRx. Maintenance prescriptions can be filled in a 90-day supply, meaning fewer trips to the pharmacy by placing only four medication orders per year. Plus, you’ll save money by doing so.

Rx Maintenance 90 Pharmacy Network (PDF) Quick References:

• Please refer to the “key’ at the bottom of each page.
• Look for the "black bullet point," which designates a participating Rx Maintenance 90 Pharmacy Network.
• Information pertaining to Ohio begins on page 511.

Definitions

The following are a few definitions that may be helpful when making your health plan choices. More definitions can be found in the Summary of Benefits and Coverage.

• Covered Services: A medically necessary service or supply for which the benefit plan will reimburse expenses according to the plan’s limits.
• Co-Payment: The fixed dollar amount you pay each time you receive specific services, supplies, or prescriptions.
• Deductible: The specified amount of covered medical expenses you pay for yourself and/or covered dependents each calendar year before any additional covered medical expenses are paid by the Plan. Applies to covered services noted as percentages.
• Co-Insurance: After the annual calendar-year deductible met, co-insurance will apply. Co-insurance is your share of the cost of a covered service. The cost is calculated as a percent of the allowed amount for the service.
• Out-of-Pocket Maximum: The maximum amount you pay in co-insurance for covered expenses in a calendar year before the Plan pays 100%.
• Usual, Customary & Reasonable (UCR): A fee usually established by health insurance or government agency that is considered to be the “usual” cost of a specific medical service. The fee is commonly based on the amount the company or agency will pay for that service and may vary with geographic area.
• Generic Prescription Drug: A prescription drug that is produced by more than one manufacturer. It is chemically the same as brand and usually costs less than the brand name prescription drug for which it is being substituted and will produce comparable effective clinical results.
• Brand Name Prescription Drug: A prescription drug that has been patented with the brand name and is produced by the original manufacturer under that brand name.

Sydney App 

All member and benefits information can be accessed via the Anthem Sydney App or, as always, on www.anthem.com.

You will be able to perform actions such as estimate costs, find care, access claims, check benefits, view ID cards, etc. In addition, there will be new actions such as chatting with a doctor or ordering medicine.

You will need to download the Sydney App and establish a new username and password to use this tool.

Disclaimer: The benefits information contained in this site provides a summary for employees of Wright State. This information does not list all the provisions and does not supersede the individual provisions of our group insurance contracts, benefit plans, and university policies that it describes. Similarly, the information presented does not guarantee that the university, the state of Ohio, and/or others responsible for these contracts, plans, programs, and policies will not make future changes in the provisions applicable to each.

Omada: Programs for Weight Loss, Diabetes, Blood Pressure, and Wellness

Human Resources is excited to announce that Wright State is partnering with Omada to offer virtual care programs at no cost to employees to help them lose weight, manage diabetes, or lower their blood pressure beginning March 1, 2024.

With Omada, members get a dedicated virtual care team of real people and a personalized health plan to help them feel better long-term.

Omada programs include:

• A welcome kit with smart devices to help monitor progress and show results; they're yours to keep
• Support from a certified coach and specialist who offers personalized guidance about nutrition, exercise, and self-care
• Access to online peer communities to share successes

The Omada program increases your chances of meeting your goals through consistent, personalized care that respects each member’s unique, day-to-day challenges. You don’t have to suffer through extreme exercise programs or crash diets and you don’t need to become a self-taught nutrition and fitness expert.

If you and/or your adult family members (18+) are at risk of (or living with) type 1 or 2 diabetes, have heart disease, are overweight, and are enrolled in a Wright State medical plan, you may be eligible for this program.  Take a 5-minute self-assessment at omadahealth.com/wsu to see if you’re eligible for this program that is being provided at no cost to you.  During the assessment, you will be asked to provide your Anthem ID number.

Questions? Contact Omada at Support@omadahealth.com.

Resources

• Omada Overview (PDF)
• Member Experience Video 60 seconds 
• FAQs (PDF)

Tobacco Cessation Program

All employees enrolled in a Wright State medical plan will be required to declare tobacco usage by completing an affidavit. Employees are considered tobacco users if they use any form of tobacco products that are smoked (e.g., cigarettes, electronic cigarettes, cigars, pipes), applied to the gums (e.g., dipping, chewing tobacco, or snuff), and/or inhaled within in the last six months.

Employees enrolled in a university medical plan who declare themselves tobacco users, as well as those who fail to complete the affidavit timely, will incur a $50 monthly surcharge (paid biweekly at $25 per pay for applicable employees).  This surcharge is intended to encourage employees who use tobacco to consider quitting tobacco while also offsetting the higher costs associated with covering tobacco users.

Ready to quit? We’re here to help.

Wright State is committed to assisting tobacco users who choose to quit tobacco use. The university is taking a variety of steps to assist employees. A reasonable alternative to the tobacco usage fee is to participate in the University’s Tobacco Cessation Program.  Tobacco users can participate in up to five resources at no cost and the $50 monthly usage fee will be initially waived.

Tobacco Cessation Program: Start today by taking a step toward a healthier tomorrow!

1. The EX Program is a digital tobacco cessation program that personalizes the quitting journey for each participant. This program includes video and digital content on preparing to quit and how to build a support system, as well as interactive tools to identify triggers and track tobacco use patterns, with tailored emails about a participant’s quit status. Versions are available to participants in both English and Spanish.
    
2. Impact Solutions, the university’s Employee Assistance Provider, offers six life-coaching sessions to help you quit. Their website and App also contain a comprehensive library of articles and tip sheets that may help.
    
3. Smokefree.gov offers a variety of resources for participants in every stage of their quit journey, from the initial wanting to quit to staying tobacco-free after quitting. Resources include a free texting program, personalized quit plans, access to quitting support apps, articles to help people prepare to quit, and information about using Nicotine Replacement Therapy.
    
4. 1-800-QUIT-NOW provides unlimited phone coaching to help you quit smoking. When you call 1-800-QUIT-NOW, you can speak confidentially with a highly trained quit coach.
    
5. Visit your Primary Care Physician (PCP). Your doctor can provide counseling advice on Nicotine Replacement Therapy and may prescribe medication to help you quit.  Click Here to view the Nicotine Replacement Therapy covered by Wright State’s medical plan at no cost to you.

Tobacco Cessation Program Participants

Periodically, program participants will be asked to provide a progress report with the expectation that participants become tobacco-free. If this occurs, participants will be moved to a tobacco-free status.  If a tobacco-free status is not achieved, the participant’s progress will determine continued eligibility for the waiver of the $ 50-a-month surcharge.

Additional Resources:

QuitGuide App helps you understand your smoking patterns and build the skills needed to become and stay smoke-free. Use the app to track your cravings by time of day and location, and get motivational messages for each craving you track.

QuitSTART App helps you quit smoking with tailored tips, inspiration, and challenges.
 

Preview for Plan Year 2025 Regarding Spouses on Wright State University Medical Plan

The Affordable Care Act requires most employers to offer medical coverage to their full-time employees. This means more spouses have access to health care coverage through their own employer. When Wright State provides coverage to working spouses who have other coverage available, this creates higher costs for employees and also for Wright State University. We want to make sure our coverage levels remain sustainable and available to those who need it most. 

Employers should be equally responsible for paying the medical plan costs of their own employees. By continuing to provide primary medical coverage for working spouses, Wright State is subsidizing other employers’ medical costs, which is not our intent. A spousal carve-out will help reduce the cost for medical coverage that Wright State is incurring instead of the spouses’ employer.

Effective January 1, 2025, if a spouse is eligible for medical coverage from their own employer, they will no longer be an eligible dependent on our medical plans. You, as an employee, will only be eligible for Employee only or Employee plus Child(ren) coverages. 

Given the significance of this change and the timing differences in the open enrollment cycles of other employers, we wanted to provide a one-year advance notice so that you might take this time to review how this will impact your personal situation and ensure you are aware of the timeframe for your spouse’s insurance election period. Further details will be forthcoming in 2024.

Qualifying Life Events

Within 31 days of experiencing a qualifying life event, you may be eligible to make consistent changes to your benefits. Please see our Qualifying Life Events section for more information.