Member Guide - Prevea360 Health Plan

2016
Member Guide
Prevea360 Health Plan is underwritten by Dean Health Plan, Inc.
Member Guide
Getting Started
3-9
CEO Welcome Message
Welcome to
Prevea360 Health Plan
Thank you for choosing Prevea360 Health Plan
as your health insurance provider. Compassionate
professionals around our network are standing
by to give you exceptional care and coverage
on day one.
New Member Checklist
Tools & Resources
Living Healthy Program
Primary Care Tips
Using Your Plan
At Prevea360, we see you as a health partner.
That’s why we empower you with resources
and services designed to promote good health.
As a member, you also get instant access to
services that are just a call or a click away:
10-17
Where to Go for Care
Prior Authorization 101
Prescription Coverage
Understanding What You Pay
• MyPrevea – your online health record
Making Changes To Your Plan
• Member Profile – your online member portal
Child Appointment Tips
Plan Details
• Prevea Care After Hours – your 24-hour nurse line
18-25
Member Rights & Responsibilities
Terms & Conditions
Privacy & Confidentiality
Limitations & Exclusions
Enrolled in Medicare?
Member ID Card Information
• Living Healthy, powered by WebMD – your wellness resource and
rewards program
Take a moment to scan this Member Guide and see how all of our
services can better serve you. We’re truly grateful to be your health
partner of choice.
Sincerely,
Ashok Rai, M.D.
President & Chief Executive Officer
Stay Informed
Sign up for Prevea360
Member News, our member
e-newsletter to get our latest news,
health tips and more. To sign up,
visit prevea360.com > For Members >
Member News.
Connect with Us!
Our Facebook page is a great
resource for helpful member
tips, health information
and more. Like us at
facebook.com/prevea360 today!
2 | Member Guide
RECOGNIZED
HIGH-QUALITY CARE
Accreditation is by the National Committee for Quality Assurance.
NCQA is an independent, not-for-profit organization that evaluates
health plans based on over 50 standards of care and service to
determine health plan accreditation.
Start Here
New Member Checklist
Begin your experience with Prevea360 Health Plan the
exceptional way. Complete the checklist in minutes to unlock
resources and take important actions so you can get the most out of
being a member.
☐
Choose a Primary Care Physician (PCP)
and Schedule an Initial Appointment
See our tips for choosing a PCP and use our online
provider directory to search our network. Call your PCP’s
clinic for an initial appointment and remember to bring
your ID card with you.
☐
Transfer Your Medical Records
☐
Activate Your Accounts
☐
Review Important Member Documents*
Once you’ve scheduled an initial appointment, transfer your
medical records from your previous clinic to your new clinic.
Contact your previous clinic to complete an Authorization
to Release Protected Health Information Form.
Complete this
checklist online.
prevea360.com/
newmember
☐
Inform Us of Your Health Concerns
☐
Inform Us of Other Insurance Coverage
If you have a chronic condition or have a complex health
care need, let us know and care management services can
help. Just contact the Customer Care Center. See page 5
for contact information.
Your Prevea360 Health Plan policy contains a
Coordination of Benefits (COB) provision to handle
multiple coverage situations if you have other insurance
coverage (either through an employer or Medicare).
Contact the Customer Care Center to inform us.
See page 5 for contact information.
Get access anytime to your personal health information with
your MyPrevea account. Have your health insurance and
member information available at your fingertips with your
Member Profile. See page 4 to learn more.
Learn about your insurance benefits and coverage with your
Member Certificate (for Individual or Group coverage).
Your Summary of Benefits and Coverage (for Individual or
Group coverage) is an easy-to-read grid that lists the details
of plan coverage, exclusions and a basic cost estimate of your
financial responsibilities. **
Check out page 25 to learn
about your ID card!
* These documents, including limitations and exclusions, are also available through your Member Profile. If you receive health
insurance through your employer, you can ask your company’s plan administrator or benefits specialist for your specific
benefits and coverage information.
** Y
our financial responsibilities may come in the form of a copayment, coinsurance or deductible. The terms stated in these
documents may change at your annual policy renewal, and we would send you an outline of any changes at that time.
prevea360.com | 3
Tools & Resources
Get the information you need, when you need it. Find it all on our
website and within member tools that easily connect you to health
information, benef it details and much more.
Activate your
accounts today.
prevea360.com/
newmember
Member
Profile
Your online
health record
Send and receive secure messages
with your primary care physician and/or
Care Management team
Get real-time lab and test results
Schedule appointments or review past
visit details
Request prescription refills
View current medical records
Pay medical bills online
Your online
member portal
View the details of your insurance
plan benefits
Change your primary care physician
Request ID cards or download a digital
ID card
Review and print claims history and
information
Check the status of prior authorizations
for services
Find your Explanations of Benefits (EOB)
Want information on the go?
Activate MyPrevea then download the
mobile app onto your smartphone.
4 | Member Guide
Tip: You’ll need your member number
from your ID card to activate your account.
Online Answers
•
prevea360.com/doctors is where you’ll find our online directory so you can search for
a provider, clinic or pharmacy near you
•
revea360.com/benefits-center contains links to important member documents with
p
information about your insurance benefits
•
revea360.com/livinghealthy is where you’ll discover a world of wellness tools
p
and resources, along with wellness rewards
Prevea Care After Hours *
Health answers anytime.
•
Call 888.277.3832
•
Available 24 hours a day, seven days a week
•
Get answers to your health-related questions or concerns
•
Talk with an experienced registered nurse
Tip: Save our number in your phone so you can call us anytime.
Customer Care Center
We’re here to help.
•
Learn more about a physician or get help choosing/changing
your physician
•
Get help figuring out what your financial responsibility is for a bill
•
Talk with someone about your benefits and coverage details
OUR KNOWLEDGEABLE STAFF ARE STANDING BY TO HELP.
Call: 877.230.7555 (TTY: 711)
Language Assistance
Monday – Thursday, 7:30 a.m. – 5 p.m.
Friday 8 a.m. – 4:30 p.m.
We are here to help all members regardless
of any language barriers that might exist.
We offer translation services and interpretation
professionals to assist with in-person and
telephone conversations, as well as written
documentation upon request, when the
member has limited English proficiency,
is deaf or is hard of hearing. Request these
services at any time.
Click: prevea360.com and
fill out the Contact Us form.
* Due to licensing regulations, Prevea Care After Hours triage phone services are only available to residents of Wisconsin.
prevea360.com | 5
Living Healthy Program
Living Healthy, our new wellness incentive program, is centered on you. Get involved
and informed on your own terms. Our program is powered by WebMD, one of the most
trusted names is health care.
LIVING HEALTHY PORTAL
Get instant access to wellness incentive offerings powered by
WebMD through your Living Healthy portal. Your portal is
interactive and personalized to your unique needs and goals.
Additional offerings are available through Prevea360 Health Plan.
LIVING HEALTHY REWARDS
Get up to $150 in wellness rewards for completing a health
assessment, having a MyPrevea and Member Profile account and
more! Plus, your adult family members can earn their own rewards
each calendar year!*
Create your
personalized
account today.
prevea360.com/
livinghealthy
* Check with your plan administrator for reward offerings specific to your plan. Only Prevea360 Health Plan members, ages 18 and older,
are eligible for Living Healthy rewards. Your employer may be required to report health plan-issued incentives as taxable income.
Prevea360 Health Plan is required to report incentive payment information to your employer. Your health information is protected by
federal law and will not be shared with your employer.
6 | Member Guide
Your Comprehensive
Wellness Program
Living Healthy
Rewards
Health
Assessment
My Health
Assistant
Interactive Tools
& Resources
Health Coach
Quit For Life®
Complex Case
Management
prevea360.com | 7
Search for an
exceptional
physician who wants a
relationship with you.
prevea360.com/
doctors
Tips for
A Better Appointment
Creating a strong, trusting relationship with a primary care physician (PCP) is at the heart of our preventive
care philosophy at Prevea360 Health Plan.
Plan Ahead
Ask Questions
Bring a list of your symptoms, including when they started,
how often they occur and what eases them before coming to
a diagnostic appointment. List any other topics you also want
to discuss with your PCP. Talk about the most important
concerns first.
Tell your PCP if you do not understand something.
Take notes or bring someone with you to take notes.
Talk about Preventive Care
For a routine or annual checkup, make sure to talk to your pcp
about what preventive screenings may be right for you and when
you should have them. See page 9 for more preventive care tips.
Bring a List of Medications
Bring a list of prescriptions and over-the-counter medications
and supplements you take, the contact information for your other
providers, a list of your allergies and any pertinent medical records
to your appointments.
8 | Member Guide
Be Open and Honest
The more your PCP knows about your lifestyle, the better he or
she is able to treat you. Be prepared to discuss details like where
you live, family medical history, your diet and sleeping habits.
Contact your PCP
If you have more questions, begin feeling worse or have problems
with medications, call or send a message through MyPrevea.
Stay Healthy with
Preventive Care
Keeping you healthy is our #1 priority. That’s why our plans typically cover preventive care services
at no additional cost to you. Let’s work together to help you avoid illness!
Annual Wellness Visits
Immunizations
Cancer Screenings
Coming in for routine preventive care
is important. Your annual wellness visit
lets your primary care physician (PCP)
become more familiar with you so he or
she can make better recommendations
about your care. Plus, these visits can
bring to light health concerns so we can
work together to address them before
they get worse. That’s what preventive
care is all about. At your visits, talk to
your PCP about important aspects of
preventive care, such as immunizations
and cancer screenings.
Immunizations have been proven
through research as one of the best ways
to prevent diseases. Talk to your PCP
about what immunizations might be
right for you and your family.
Cancer is most treatable when it’s
detected early with cancer screenings.
Some adults, depending on their
age, family history, gender or other
risk factors, may have an increased
risk for cancer. Ask your PCP if you
should be screened at an earlier age
or more often. You can also visit
uspreventiveservicestaskforce.org
to learn more about recommended
cancer screenings.
Visit prevea360.com/immunizations to:
• Check if you and your family are
up-to-date on your immunizations.
• Learn about when and what
immunizations should be given to
children, teens and adults.
Complete an annual preventive
visit to help you earn up to $150 in Living
Healthy rewards! Visit prevea360.com/
livinghealthy to learn more.
See a listing of
available services that
can help you stay healthy.
prevea360.com/
preventivecare
To see your specific preventive care coverage details, please review your Member Certificate and Summary of Benefits and
Coverage documents. For coverage questions, contact the Customer Care Center.
prevea360.com | 9
Where to Go for Care
Whenever you need care (except emergencies), start by calling your primary care physician (PCP)
for the soonest available appointment or for help deciding where to go.
Urgent Care
Call your PCP first when you think you need urgent care. If a
same-day appointment is not available to treat your illness or injury,
you may be directed to go to Urgent Care. Common reasons to visit
include: migraines and minor burns, sprains or strains.
Higher copays are possible with this option.
Emergency Care
Learn more about
getting the right care,
in the right place, at the
right cost.
prevea360.com/
rightcare
For a life-threatening illness or injury, go to the nearest emergency room or
call 911. Tell your PCP that you went to the emergency room because he or she
might determine that you need follow-up services. Common reasons to visit include:
heart attack (chest pain, shortness of breath, nausea/vomiting), stroke (slurred speech,
sudden weakness and vision loss) and head trauma or sudden confusion.
The high-cost option.
?
Not Sure?
An experienced, 24-hour nurse at Prevea Care After Hours is always available to answer
your health questions.* Call 24 hours a day, 365 days a year at 888.277.3832.
* Due to licensing regulations, Prevea Care After Hour’s triage phone services are only available to
residents of Wisconsin.
SPECIALTY CARE
In addition to primary care, the Prevea360 network includes a variety of medical specialties. Your PCP can help you
select the specialist who is right for you. Visit prevea360.com/doctors for a comprehensive list of Prevea360’s
specialty providers, behavioral health services and hospitals. A prior authorization by Prevea360 Health Plan might
be needed for certain medical services or specialty care services from a specialty provider.
We require prior authorization so our medical management team can review the medical necessity of the
recommended service or visit and make sure you are getting appropriate care.
A prior authorization can only be obtained for services that are covered under your plan benefits. For example,
if bariatric surgery is an exclusion of your policy, prior authorization will not change that benefit. If the services
are covered under your plan, they are also still subject to medical necessity and any applicable cost sharing
(e.g., copays, coinsurance or deductibles).
A good rule to remember is that any time you seek services with an out-of-network provider, you will need to obtain
prior authorization. See the chart on the next page.
10| Member Guide
10
Do I Need Prior Authorization?
A prior authorization by Prevea360 Health Plan might be needed for certain medical services or specialty
care services from a specialty provider. It depends on your insurance plan:
I have a Network plan
Did your primary care physician (or other in-network
provider) refer you to an in-network or out-of-network
provider/specialist for the recommended service?
In-Network
Though the service may require
a prior authorization,
it is up to your in-network
provider to obtain a prior
authorization for you.
Out-of-Network
For any services performed by an out-ofnetwork provider, it is up to you to
secure a prior authorization. Just ask
the recommending plan provider to
contact our Customer Care Center to
submit a prior authorization request.
Prevea360 Health Plan will then review
the request and provide a written
decision to both you and the plan
provider within 15 business days.
Make sure you wait until you receive
this approval before receiving the
recommended services to avoid any
unnecessary fees.
Out-of-Area Coverage
Urgent & Emergency Care: Both urgent and emergency care are
covered under your plan if you are not able to return to the Prevea360 Health
Plan service area for immediate treatment and if the medical need is determined
as urgent or emergent upon review. If you require urgent or emergency care
outside the service area and are unable to get to a plan provider, please go to the
nearest urgent care or emergency center for treatment. Notify Prevea360 as soon
as possible by contacting the Customer Care Center (see page 5 for contact
information). All follow-up care should be done by a plan provider; if you are
out of the area and not able to see a plan provider, call your primary care
physician for a referral to an out-of-area provider. These services require
approval by Prevea360 Health Plan.
I have a POS or PPO plan
Because each POS and PPO plan is
different, we recommend you check to see
if a prior authorization is required for any
services outside a normal office visit.
For a plan-specific list of these services,
refer to the “Prior Authorization” section of
your Member Certificate available at
prevea360.com.You may also call
877.230.7555 for help.
Visit prevea360.com > For Members >
Using Your Plan to learn more.
HAVE QUESTIONS
OR NEED HELP?
Have a question about prior authorization
or other issues related to utilization
management services? Contact the
Customer Care Center.* See page 5
for contact information.
* If the Customer Care Center is unable to address your authorization concerns, they will connect you to the Utilization
Management Department. If you have an urgent need outside of business hours, leave a message with the Customer Care
Center and your call will be returned within one business day.
prevea360.com | 11
Find a pharmacy,
view your drug
formulary and learn more
about pharmacy services.
prevea360.com/
pharmacybenefits
Understanding
Prescription Coverage
We offer a variety of cost savings programs like mail-order prescriptions, pill splitting and generic
sampling programs to help you manage your prescriptions and lower your expenses.
Your prescription coverage with Prevea360 Health Plan is based on a drug formulary, or list of drugs, used by Prevea360 Health Plan
to help you differentiate what is and isn’t covered. Our drug formulary breaks the list into tiers, indicating different levels of cost sharing.
Go online to see the drug formulary for your plan. You can search by drug name, type or tier. You can also calculate how much you can
expect to pay for drugs in each tier by logging in to your Member Profile and using the What’s My Copay? tool.
As with most health coverage, there are limitations to prescription drug coverage that help keep plan costs down. Make sure you are
familiar with both your plan’s specific coverage details and our general limitations and procedures.
Formulary Management Procedures
The Prevea360 Health Plan drug formulary is reviewed every month and updated on a regular basis. For example, we update the drug
formulary when a new generic drug is approved. Restrictions and limitations apply to the drug formulary, when necessary:
• We use a closed formulary. That means if a drug is not
listed on your drug formulary, the product is not covered by
your pharmacy benefit. If you choose a product not on the
formulary, you are responsible for 100 percent of the cost
of the drug. You have the right to request coverage for
non-formulary drugs through our exception process.
For more information, contact the Customer Care Center.
See page 5 for contact information.
• When a drug needs prior authorization, the provider must
receive approval prior to Prevea360 Health Plan paying its
share of the prescription cost. You would be responsible
for 100% of the cost of the drug if the drug requires a prior
authorization. Visit prevea360.com/pharmacy for the list
of drugs that require prior authorization and request forms.
For coverage questions, contact the Customer Care Center.
See page 5 for contact information.
• We may require a mandatory generic substitution.
If the generic version of the drug is mandated and you
choose to receive the brand, you are responsible for
the highest tier branded copay plus the ingredient cost
difference between the brand and generic versions.
12| Member Guide
12
If your provider requests the branded version, you are only
responsible for the highest tier branded copay.
• Step therapy is a practice in which prescriptions are filled
with the most affordable (Step 1) choice of medication
first. If the Step 1 medication is ineffective in treating the
condition, a patient may then receive authorization to try a
more costly (Step 2) medication. Step 2 medications will
not be covered under your benefit until Step 1 medications
are tried first.
• Specialist restriction means that only a certain type
of specialist can prescribe a particular drug. These
decisions are based on the indications and uses for the
specific drug.
• Quantity level limits restrict the supply of drug product
that may be dispensed either per prescription or for a
specific amount of time.
• If a drug is available or mandated to be dispensed by a
specialty pharmacy, the Specialty Pharmacy designation
will be applied.
Tips for Taking Medications
Used incorrectly, some medications can do more harm than good. So whether you’re starting a new prescription
or shopping for cold medicine, the details do matter.
Ask About Medications
Taking Over-The-Counter Medicine
When prescribed a medication, ask your primary care physician
(PCP) the following questions to make sure you use it correctly.
Make sure to write your answers down. When you pick up the
prescription, check that it is the same one your PCP prescribed.
Just because you can buy over-the-counter medicine
without a prescription doesn’t mean they’re free
of side effects or hazards. Before taking
over-the-counter medicine, check with your
PCP or pharmacist to make sure it’s safe
in combination with any other medications
you are taking. When reading the label,
look for dosage information, warnings
and the expiration date. Before you
buy an over-the-counter medicine,
make sure the tamper-resistant seal
has not been broken.
• What’s the name of the medicine?
• How often should I take it, at what dosage and when?
• For how long should I take it?
• What side effects are possible? What should I do if
they occur?
• What foods, drinks or other medications should I avoid
while taking the medicine?
• What should I do if I forget a dose?
How to Take Medications
Never chew, crush, break or dilute any capsules or tablets
unless the directions indicate that you should. This may
cause long-acting medications to be absorbed too quickly.
Many liquid medications come with a plastic cup that holds just
the right amount. If not, ask your pharmacist for a cylindrical
dosing spoon or an oral syringe, which is especially useful with
small children and elderly people. Or use a measuring spoon as
ordinary spoons vary in size.
prevea360.com | 13
Understanding
What You Pay
At Prevea360 Health Plan, we provide you with tools to learn where your health care
dollars go, how much you are charged for health services in terms of cost sharing and
your amount of f inancial responsibility.
Your Prevea360 Health Plan policy may use a system of cost sharing that can include a copay,
coinsurance, deductible or any combination of the three. Cost sharing is used by most health plans and is
the amount that you are financially responsible for after getting medical care. Cost sharing helps keep
monthly premiums low and adds flexibility to health plans, allowing you to tailor your health coverage to
your usage. Be sure to check your policy to understand which of these apply to you:
• A copay is a fixed amount that you pay for a covered health care service, usually when you get the
service. The amount can vary by the type of covered health care service.
• A deductible is the amount you owe for health care services covered by a health plan before the plan
begins to pay. For example, if your deductible is $1,000, you pay the first $1,000 for covered health care
services subject to the deductible, then Prevea360 Health Plan starts to pay. The deductible may not
apply to all services.
• Coinsurance is your share of the costs of a covered health care service, calculated as a percent of the
allowed amount for the service. You pay coinsurance plus any deductibles you owe first. For example,
if Prevea360 Health Plan’s allowed amount for an office visit is $100 and you’ve met your deductible,
your coinsurance payment of 20 percent would be $20. Prevea360 Health Plan pays the rest of the
allowed amount.
• The annual maximum out-of-pocket is the maximum you will pay for covered services in a plan year.
All charges above this amount will be paid in full by Prevea360 Health Plan. You can find details about
your maximum out-of-pocket in your Member Certificate, Schedule of Benefits or at prevea360.com.
14| Member Guide
14
Explanation of Benefits
If you have a financial responsibility after you use your health plan for a covered service, you will be
issued an Explanation of Benefits (EOB). The EOB details charges and your financial responsibility
due to any deductibles or co-insurance. Your EOB is not a bill, but a breakdown of services used,
amount charged by the provider and the amount that you are financially responsible for. You can see
your prior EOB documents any time by logging in to your Member Profile.
Making Payments
• Paying Your Insurance Premium
If you are a Prevea360 individual and family plan member and your premiums are not
auto-withdrawn from your paycheck, you have access to a number of convenient ways to pay
your monthly premium. We can accept online payments as well as payment through the mail.
We can also accept cash payments at a CheckFree® kiosk near you.
• Paying for Medical Services
When you are seen at a clinic location for services, you will often have the option to pay an
applicable copay upon check-in. Prevea Health will bill you for any deductibles for which you may
be responsible. Prevea Health will mail you a bill for any copay changes not paid at the time of
service or any coinsurance for which you are financially responsible. When you receive a bill this
way, you may send in a check or provide your credit card information on the payment form and
send it back to us.
• How to Submit a Claim
In most cases, claims are submitted directly to Prevea360 Health Plan by the providers or clinics.
On occasion, if you’re traveling out of the area or have a college-age dependent, for example,
it may be necessary for you to submit a claim for reimbursement. When submitting the claim,
be sure to follow these guidelines:
• Send an itemized bill from the provider of service. If services were received outside of the
United States, you will need to submit the original bill along with an itemized bill that has
been translated into English and indicate the appropriate currency exchange rate at the time
the services were received.
• Send the bill within 60 days after the services are received to: Prevea360 Health Plan,
Attn: Claims Department, P.O. Box 56099, Madison, WI 53705.
If you have another insurance company that is the primary payer, you will need to send the
Explanation of Benefits to Prevea360 Health Plan or your health care provider.
GETTING A COST ESTIMATE FOR MEDICAL SERVICES
Your Summary of Benefits and Coverage (SBC) document contains a sample cost estimate of
common medical events/services. Access this document through your Member Profile. You may
also call the Customer Care Center at 877.230.7555 and provide the following information:
Name of your physician
Current Procedural Terminology
(CPT) code*
Date of service*
Amount that your provider is billing*
Name of medication and dosage
(if applicable)
GETTING A COST ESTIMATE FOR PRESCRIPTION DRUG
You can use the What’s My Copay? tool in the "View Pharmacy Information" section in your
Member Profile to see your out-of-pocket cost for prescription drugs. You may also contact the
Customer Care Center at 877.230.7555 for assistance.
* This information may be obtained by contacting your physician.
prevea360.com | 15
Sometimes big events happen in your life and it means you need to make a change to your coverage with
Prevea360 Health Plan. We can help.
You can make changes to your plan outside of the designated open enrollment period (whether you purchased coverage on or off the
Health Insurance Marketplace), but only if you have a qualifying event that would trigger a special enrollment period. If you get
your coverage through your employer, please contact your benefits administrator to make a change.
Special enrollment periods, which were created by the Affordable Care Act (ACA), gives consumers a limited time period after a
qualifying event to purchase new individual health insurance or make changes to an existing policy, like adding a dependent or
changing plans.
What are Qualifying Events?
How Long is Special Enrollment?
In general, a qualifying event occurs when your family, health
insurance or financial status changes throughout the year.
Examples include:
Typically, consumers have a specified number of days from
when a qualifying event occurs to make plan changes.
Since different qualifying events have different time frames,
we recommend you review our special enrollment page at
prevea360.com/specialenrollment for more information on
qualifying event requirements.
• Birth/Adoption
• Permanent Move
• Marriage
• Loss of Coverage
Learn how to make changes to
your plan and see if you qualify.
prevea360.com/specialenrollment
16| Member Guide
16
Child Appointment Tips
Preparing for a visit with your child’s primary care physician (PCP)
can help you and your child get the maximum benef it from the
appointment and make the experience easier.
A trip to the clinic can be challenging for some children. Here are some tips to
help your little one cope:
• Be honest and tell your child what to expect. For example, you could say that
vaccinations will hurt, but only for a minute or so.
• Ask to be with your child during procedures whenever possible. This can ease
anxiety for both you and your child.
• Use a toy or musical instrument to distract your child during shots or other
uncomfortable moments. Let them know it’s okay to cry.
• Before the appointment, talk with other people who know your child well,
such as a grandparent or caregiver, to see if they have a concern. They may
know things you don’t.
You should also prepare for the appointment so you can make the most of the time
with the doctor. Bring written lists of the following:
GET AN
IMMUNIZATION
SCHEDULE
Routine immunizations
protect your child’s health.
Immunizations are safe and
effective, and today we can
protect children from 14 serious
diseases. Well Child Visits are the
ideal opportunity to receive the
appropriate immunizations. Visit
prevea360.com > For Members
> Immunizations to download a
detailed Immunization Schedule
and Record and to find out when
your child should have his or her
Well Child Visits.
• Specific questions or concerns that you have
• Medications your child is taking
• Immunizations your child has received
NEW MEDICAL TECHNOLOGY
Each year, we evaluate new and existing medical technology to determine if any updates are needed.
Drugs covered under your pharmacy benefit are also reviewed by a Prevea360 Health Plan medical
director and pharmacists from Prevea Health System and Navitus Health Solutions. Whether a product or
process is reviewed before or after implementation, Prevea360 Health Plan follows the review process set
by the National Commission for Quality Assurance (NCQA). Based upon the results of the technology
assessment, Prevea360 Health Plan will revise its medical policies if necessary.
prevea360.com | 17
Member Rights and Responsibilities
You deserve the best service and health care possible. Rights and responsibilities help foster cooperation among
members, practitioners and Prevea360 Health Plan.
MEMBERS RIGHTS:
MEMBERS RESPONSIBILITIES:
• Be treated with respect and recognition of their dignity and
• Read and understand the materials provided by Prevea360
right to privacy.
• Receive a listing of Prevea360 Health Plan participating
practitioners in order to choose a primary care physician.
Health Plan concerning their health care benefits.
We encourage members to contact Prevea360 Health Plan if
they have any questions.
• Present a question or complaint or grievance to Prevea360
• Present their ID card in order to identify themselves
• Receive information on procedures and policies regarding their
• Notify Prevea360 Health Plan of any enrollment status
• Timely responses to requests regarding their health care plan.
• Supply information (to the extent possible) that the
Health Plan, about the organization or the care it provides,
without fear of discrimination or repercussion.
health care benefits.
• Request information regarding Advance Directives.
• Participate with practitioners in making decisions about their
as Prevea360 Health Plan members before receiving
health care services.
changes such as family size or address.
organization and its practitioners and providers need in order
to provide care.
health care.
• Follow plans and instructions for care that they have agreed on
treatment options for their conditions, regardless of cost or
benefit coverage.
• Understand their health problems and participate in
its practitioners and providers, and members’ rights and
responsibilities.
• Fulfill financial obligations as it relates to any copays,
• A candid discussion of appropriate or medically necessary
• Receive information about the organization, its services,
• Make recommendations regarding the organization’s members’
rights and responsibilities policies.
• Receive a copy of the Prevea360 Health Plan Notice of
Privacy Practices, which describes how medical information
about you may be used or disclosed and how you can get
access to this information. The Notice is available at
prevea360.com/privacy.
18| Member Guide
18
with their practitioners.
developing mutually agreed upon treatment goals to the
degree possible.
deductibles and/or premiums as outlined in your policy.
• Provide information about any other health insurance coverage
you have so that Prevea360 Health Plan can coordinate
benefits with the other insurance plan(s).
Prevea360 Health Plan
Terms & Conditions
1. By signing this Application, I understand and agree
that: (a) all statements and answers I have given
are complete and true to the best of my knowledge
and belief; (b) the insurance I hereby apply for
will be effective only when Prevea360 Health
Plan approves this Application. Evidence of such
approval will be the issuance of ID Card(s), which
will be delivered to the group or employee. The
effective date will be the date shown on the I.D.
card issued; (c) the Social Security numbers I have
provided may be used for I.D. purposes; and (d)
if my or my dependents’ health has changed from
what is indicated on the Application prior to the
effective date of coverage, I will notify Prevea360 of
the change immediately, if applicable. Any person
who knowingly presents a false or fraudulent claim
within the contestable period for payment of a loss
or benefit or knowingly presents false information
in an Application for insurance is guilty of a crime
and may be subject to fines and/or imprisonment
under Wis. Stat. 943.395. I further understand
that, in the event of fraud or misrepresentation, this
information may be used to reduce or deny a claim,
void coverage, or void the group contracts within the
contestable period, if such misrepresentation affects
Prevea360’s acceptance of risk.
2. By my signature on this application, I authorize:
(a) Any physician, medical practitioner, hospital,
clinic, medically related facility or other institution
who provided treatment or service to me, my
spouse or my minor child(ren) at any time, or their
agent(s) (including billing service), having medical
information which includes, but is not limited to,
identification, medical history, diagnosis, prognosis,
consultations, advice, treatments, services, dates of
treatments and/or services, test results (excluding
genetic tests and FDA-licensed blood tests for the
presence of HIV, but including X-rays), summary
reports, without limitation to period of treatment,
diagnostic or therapeutic information, history or
type of injury or illness (including pregnancy and
treatment or service, if any, for mental or nervous
conditions, alcohol abuse or drug abuse), and (b)
Any insurance or reinsuring company, service or
prepaid benefit plan, plan administrator, consumer
reporting agency, employer or personal or business
associates having non-medical information about
me, my spouse, or my minor child(ren), concerning
eligibility and claim administration to disclose to
Prevea360, or their representatives (including the
claims department) all such information.
I understand that when used for the purposes of
obtaining information in connection with claims
for benefits, utilization review, quality improvement,
health care operations or other activities as
permitted by law, this Authorization is valid during
the Policy term or pendency of the claims for
benefits, whichever is longer. I understand that I
may request and receive a copy of this authorization.
3. I understand that any approved coverage is not
effective for me or my dependents if I am not
actively at work at my full-time employment with
my employer on the assigned effective date, but
that such coverage will first become effective on the
first day thereafter that I am actively working at
such employment.
4. This Application, when approved, and any
endorsement, amendment, or rider thereto, will be
made part of the contract(s) applied for.
5. No person, except an officer of Prevea360, is
authorized to vary or modify a contract. I further
understand and agree that Prevea360, its directors,
officers, employees, and agents shall not be liable for
any injury, damage, or expense (including attorney’s
fees) that I or any of my dependents suffer as a result
of any improper advice, action, or omission on the
part of any health care provider.
6. Subject to the acceptance of the Application by
Prevea360, I authorize the group, as my remitting
agent and until this authorization is revoked in
writing, to deduct from my wages or salary a
sufficient amount to provide for the regular and
timely prepayment of the prevailing subscription
fees that are not otherwise contributed by my
employer for the contract(s) applied for and to remit
the same on my behalf to Prevea360.
7. The contract(s) applied for will become void if and
when I cease to be employed or affiliated with the
group. Should I wish to retain my membership after
such termination, it shall be my responsibility to
secure a new application form from Prevea360
and to apply for the programs then being offered to
such individuals.
prevea360.com | 19
Privacy and Confidentiality
This notice describes how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
Protecting the Privacy of Your Personal
Health Information
How Prevea360 May Use or Disclose Your
Health Information
Prevea360 is required by law to maintain the privacy of
your personal health and financial information (collectively
referred to as “nonpublic personal information”) and provide
you with written notification of our legal duties and privacy
practices concerning that information. This Notice describes
how we protect the confidentiality of our members’ (and
former members’) nonpublic personal information. It includes
brief explanations on how we obtain, use, and protect your
nonpublic personal information.
We will not disclose your nonpublic personal information
unless we are allowed or required by law to do so. The
following categories describe the ways that Prevea360 may
use and disclose your nonpublic personal information. For
each category of uses and disclosures, we will explain what
we mean and present some examples. Not every use or
disclosure we might make will be listed. However, all the
ways we are permitted to use and disclose information will
fall within one of the categories.
Types of Nonpublic Personal Information
Prevea360 Collects About You
We collect a variety of nonpublic personal information
needed to administer health insurance coverage and benefits.
We collect nonpublic personal information about you from
some of the following sources:
•
•
•
Information we receive directly or indirectly from you
or your employer or benefits plan sponsor through
applications, surveys or other forms. The information
may be received in writing, in person, by telephone
or electronically. Examples include name, address,
social security number, date of birth, marital status and
medical history.
Information about your transactions with us, our
affiliates, our providers, our agents and others. This
includes information from health care claims, medical
history, eligibility information, payment information,
service request, and appeal and grievance information.
Information you authorize us to collect from others.
Choices About Your Health Information
We will not use or disclose your health information without
your written authorization, except as described in this Notice.
You generally have the right and choice to tell us to:
•
Share information with your family, close friends or
others involved in payment for your care.
•
Share information in a disaster relief situation.
In the following cases we never share your information
unless you give us written permission:
•
Most uses and disclosures of psychotherapy notes.
•
Marketing purposes.
•
Sale of your information.
If you do give us written authorization to use or disclose your
health information for a particular purpose, you may change
your mind at any time. You must let us know in writing if you
change your mind.
20| Member Guide
20
Note: Some of the uses and disclosures described in this
notice may be limited in certain cases by applicable State
laws that are more stringent than Federal laws, including
disclosures related to mental health and substance abuse,
developmental disability, alcohol and other drug abuse
(AODA), and HIV testing.
We are allowed to use and disclose information that falls
within one of the following categories:
1. Payment. We may use and disclose your health
information to make and collect payment for
treatment and services you receive, such as:
determining your eligibility for plan benefits,
obtaining premiums, determining your health plan’s
responsibility for benefits, and collecting payment for
your health services.
2. Health Care Operations. We may use and disclose
your health information to support our business
activities and improve our coverage and services.
However, we are not allowed to use genetic
information to decide whether we will give you
coverage or the price of that coverage. Health care
operations include such activities as:
•
Underwriting
•
Premium rating
•
Other functions related to plan coverage
•
Quality assessment and improvement activities.
•
Activities designed to improve health and reduce
health care cost.
•
Case management and care coordination.
3. Treatment. We may disclose your health information to
a physician or other health care provider that is treating
you. We may contact you with information on treatment
alternatives and other related functions that may be of
interest to you.
4. Distributing Health-related Benefits and Services.
We may use and disclose your health information to
provide information on health-related benefits and
services that may be of interest to you.
5. Disclosure to Plan Sponsors. If applicable, we may
disclose your health information to the sponsor of your
group health plan for purposes of administering benefits
under the plan. If you have a group health plan, your
employer is the plan sponsor.
3. Right to See and Copy. You have the right to see and
copy certain health information about you.
6. Public Safety. We can share health information about
you for certain situations such as: preventing disease;
helping with product recalls; reporting adverse reactions
to medications; reporting suspected abuse, neglect,
or domestic violence; and preventing or reducing a
serious and imminent threat to the health or safety of a
particular person or the public.
5. Right to Accounting of Disclosures. You have the right
to receive a list or “accounting of disclosures” of your
health information made by us in the past six years.
The list will not include disclosures made for purposes
of treatment, payment, health care operations, or
certain other disclosures (such as those you asked us
to make).
7. Research. Under certain circumstances, and only after
a special approval process, we may use and disclose
your health information to help conduct research.
6. Right to Copy of Notice. You have a right to receive a
paper copy of this Notice at any time.
8. Required by Law. We will share information about you if
laws require it, including with the Department of Health
and Human Services if it wants to see that we are
complying with federal privacy law.
9. Workers’ Compensation, Law Enforcement, and Other
Government Requests. We can use and share health
information about you: for workers’ compensation
claims; for law enforcement purposes or with a law
enforcement official; with health oversight agencies for
activities authorized by law; and for special government
functions such as military, national security, and
presidential protective services.
10. Legal Actions. We may disclose your health
information in the course of any administrative or
judicial proceeding.
How Prevea360 Protects This Information
We limit the collection of nonpublic personal information to
that which is necessary to administer our business, provide
quality service, and meet regulatory requirements. We
maintain physical, electronic, and procedural safeguards
that comply with federal regulations to safeguard your
nonpublic personal information. We limit the internal
use of oral, written, and electronic nonpublic personal
information about you and ensure that only authorized
staff and business associates with the need to know have
access to it. We maintain safeguards for your nonpublic
personal information and review them regularly to protect
your privacy.
4. Right to Correct Records. You have a right to request
that Prevea360 correct certain health information held
by Prevea360 if you think it is incorrect or incomplete.
7. Right to be Notified of a Breach. You will be notified
in the event of a breach of your unsecured protected
health information.
Changes to this Notice of Privacy Practices
Prevea360 may change this Notice from time to time and
make the new provisions effective for all nonpublic personal
information we maintain, including information we created or
received before the change. Prevea360 will always comply
with the current version of this Notice.
Complaints
Please submit complaints about this Notice or how we
handle your health information, in writing, to our Privacy
Officer. Prevea360 will not hold any complaint you submit
against you in any way. In addition, if you believe your
privacy rights have been violated, you may file a complaint
with the Secretary of the U.S. Department of Health and
Human Services.
If you have questions, complaints or want to exercise any of
your health information rights, call the Customer Care Center
at 800.279.1301 (or, if you purchased coverage on the
Health Insurance Marketplace, at 800.279.1302) or contact
us at the following address:
Privacy Officer
PO Box 56099
Madison, WI 53705
The effective date of this notice is November 24, 2015.
Your Health Information rights
1. Right to Request Restrictions. You have the right to
request restrictions on certain uses and disclosures of
your health information.
2. Right to Request Confidential Communications. You
have the right to receive your health information
through a reasonable alternative means or at an
alternative location.
prevea360.com | 21
Limitations & Exclusions
All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in either your
Policy and Benefit Summary (“Policy”) if you have individual coverage or your Group Member Certificate (“Certificate”) if you
have coverage through your employer. The following list is not exhaustive and may vary based on your Policy or Certificate.
For a complete listing refer to your specific Member Policy or Certificate. See page 3 to learn how to f ind your Policy or Certif icate.
Medical
• C
ytotoxic testing and sublingual
antigens in conjunction with
allergy testing.
• R
eplacement of an item if the item is
lost, stolen, or unusable/nonfunctioning
because of misuse, abuse, or neglect.
• H
air analysis (unless lead or arsenic
poisoning is suspected).
• S
exual dysfunction and sexual
transformation supplies, including but
not limited to medications and
injections, unless mandated by law or
covered under our medical policy.
• P
reimplantation genetic testing of
embryos and gametes.
• C
onvenience items for a Member or a
Member’s family, unless otherwise
specified in this policy.
• D
rugs provided in conjunction with the
treatment of infertility, including but
not limited to those administered in a
physician’s office.*
• O
utpatient prescription drugs, except
those prescriptions otherwise covered
under this Policy.
• O
ral Nutrition: Oral nutrition is not
considered a medical item. We do not
cover nutritional support that is taken
orally (i.e., by mouth), unless mandated
by state law or covered under Our
medical policy for a specific condition.
Examples include, but are not limited
to, over-the-counter nutritional
supplements, infant formula, and donor
breast milk.
• Autopsy.
• C
harges or costs relating to
donor sperm.
• C
onsultation for, or procedures in
connection with, in vitro fertilization,
embryo transplantation, and/or any
other assistive reproductive technique
(e.g. GIFT, ZIFT).
• C
osmetic services, including cosmetic
surgery. Experimental or investigational
services, treatments, or procedures,
and any related complications as
determined by Our Medical Affairs
division, unless coverage is required by
state or federal law.
• I nfertility-related services or
procedures.*
• Infertility-related services or procedures
not otherwise covered by this policy,
including but not limited the collection
and storage of sperm and eggs outside
the course of treatment for, and
diagnosis of, infertility, including for
surrogacy or Gestational Carriers.*
• L
aser treatment for Port Wine Stain
(PWS) lesions, except on the face
and neck.
• P
odiatry services or routine foot care
rendered in the absence of localized
illness, injury, or symptoms in
connection with, but not limited to: (a)
the examination, treatment, or removal
of all or part of corns, calluses,
hypertrophy or hyperplasia of the skin
or subcutaneous tissues of the feet; (b)
the cutting, trimming, or other nonoperative partial removal of toenails; or
(c) for any treatment or services in
connection with any of these.
• O
besity-related services, including any
weight loss method, unless specifically
covered under this Certificate.
• R
eversal of voluntary sterilization and
related procedures.
• Services related to surrogacy.
• S
exual dysfunction and sexual
transformation treatment and services
including but not limited to surgical
treatment, unless mandated by law or
covered under our medical policy.
• Sterilization procedures for men.*
• S
terilization procedures for women and
patient education and counseling related
to contraception for all women with
reproductive capacity. (Although these
are technically excluded from your
group’s health plan insurance coverage,
they will be paid for as preventive
services by Prevea360 Health Plan,
as required by federal regulations).*
22| Member Guide
22
• Travel immunizations.*
• Acupuncture.*
• B
ehavioral health therapy services
provided in the home.
• Chelation therapy for atherosclerosis.
• Coma stimulation programs.
• Dry needling.
• H
olistic medicine and any other form
of alternative medicine.
• Low Level Light Therapy.
• Massage therapy.
• Prolotherapy.
• S
wim or pool therapy, unless Prior
Authorization is obtained.
Non-Medical
• A
dministrative examinations such as
employment, licensing, insurance,
adoption, or participation in athletics.*
• C
ourt-ordered care, unless Medically
Necessary and otherwise covered
under this Certificate.
• E
ducational services, except for
diabetic self-management classes.
• I nternet and phone consultations,
including all related charges and
costs, except as defined by our
medical policy.
• Missed appointment charges.
• T
elephone consultation charges by or
between providers.
• C
harges or costs exceeding a benefit
maximum or Maximum Allowable Fee
where applicable.
• E
xpense incurred before the supply
or service is actually provided unless
prior approved by Our Medical
Affairs division.
• S
ervices, treatment, and supplies
provided to a Member while the
Member is held or detained in custody
of law enforcement officials, or
imprisoned in a local, state, or federal
penal or correctional institution.
• S
ervices and supplies furnished by
a government plan, hospital, or
institution unless by law you
must pay.
• S
ervice for hospital or medical care
not listed in this Certificate.
• S
ervices, treatment, and supplies
provided in connection with any illness
or injury caused by: (a) a Member’s
engaging in an illegal occupation or
(b) a Member’s commission of, or an
attempt to commit, a felony. (Note
that this exclusion does not apply to
the treatment of injuries that result
from an act of domestic violence, to
the extent that such treatment would
otherwise be covered.)
• S
ervices provided by members of the
Subscriber’s Immediate Family or any
person residing with the Subscriber.
• S
ervices or supplies for, or in
connection with: a non-covered
procedure or service, including
complications, regardless of when a
non-covered procedure or service is or
was performed; a denied Prior
Authorization; or a denied admission.
• S
ervices and supplies rendered outside
the scope of the provider’s license.
• S
ervices or items required as a result of
war or any act of war, insurrection, riot,
terrorism, or sustained while
performing military service.
• S
ervices to the extent a Member
receives or is entitled to receive any
benefits, settlement, award, or damages
for any reason of, or following any
claim under, any Workers’
Compensation Act, employer’s liability
insurance plan, or similar law or act.
“Entitled” means the Member is
actually insured under Workers’
Compensation.
* Indicates language that will likely vary
in your Policy or Certificate.
Last updated November 24, 2015.
• S
ervices or supplies not Medically
Necessary, not recommended or
approved by a provider, or not
provided within the scope of the
provider’s license.
PREVEA360 HEALTH PLAN’S GRIEVANCE AND
EXTERNAL INDEPENDENT REVIEW RIGHTS
We know that at times you may have questions and concerns about benefits,
claims or services you have received from Prevea360 Health Plan. When a
question or concern arises, we encourage you to reach out to our Customer Care
Center. Our Customer Care Specialists will make every effort to resolve your concern
promptly and completely. Your input matters, and we encourage you to call with
any concerns you may have regarding your health care.
If after contacting us, you continue to feel a decision has adversely affected your
coverage, benefits or relationship with Prevea360 Health Plan, you may file a
grievance (sometimes called an appeal). For details on how to file or for more
information about these procedures, please visit prevea360.com/appeals. You may
also find information in your Member Certificate or Summary. Contact the Customer
Care Center with any questions about the process. See page 5 for contact
information and hours.
prevea360.com | 23
Let Us Know If You Are Enrolled in Medicare
We understand that Medicare coverage can be confusing—especially when it comes to the coordination of benef its
(COB) between Medicare and your current employer-sponsored or other insurance plan, such as individual
insurance. So as you become Medicare eligible, please let us know as soon as you enroll in Medicare coverage.
Why do we need to know?
To ensure the medical accuracy of claims and, ultimately, to ease the COB process for you! When we coordinate benefits with Medicare,
there are different rules for employer-sponsored insurance plans and individual insurance plans.
• If you are insured under any individual insurance plan, Medicare will pay first as the primary plan
• If you are insured under an employer-sponsored insurance plan, who pays as primary may vary. The following criteria govern whether
Prevea360 or Medicare will pay first as the primary plan:
1. The reason for Medicare eligibility
2. Work status (currently working, retired, COBRA, leave of absence, severance, etc.)
3. The number of employees working for your employer
For both individual insurance plans and employer-sponsored insurance plans, it is important to keep the following in mind: If a member is
eligible for Medicare and Medicare would be the primary plan for that member, Prevea360 Health Plan strongly suggests that the member
enroll in Medicare Part A and Part B. Failure to enroll in Medicare Part A and B will result in the member paying out-of-pocket expenses
for services that Medicare might have covered, because Prevea360 Health Plan will process the member’s claims as if the member is
enrolled in Medicare. For more information please see the “Payment of Claims” subsection of the Coordination of Benefits chapter in your
individual Member Policy or your employer-sponsored Member Certificate.
24| Member Guide
24
How to Read Your Member ID Card
4
5
1
6
2
3
Card Front
7
8
Card Back
1. Number to call for claims and insurance
2. Your out-of-pocket copay costs*
3. For pharmacy use
4. N
etwork: Plan/geographic area
Product Type: Plan you purchased and providers you can see
5. Prevea Care After Hours 24-hour Nurse line
6. U
se the member number to look up member certificate (plan benefits
information) online at prevea360.com
7. When possible, go to your primary care provider first
8. For urgent care or medical emergency
*Copay: Fixed amount when you receive care
Deductible: Amount you pay before insurance pays
Emergency Room Copay: Paid if you aren’t
admitted (see member certificate for more details)
prevea360.com | 25
26| Member Guide
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prevea360.com | 27
Prevea360 Health Plan SM
PO Box 28467
Green Bay, WI 54324-0467
p. 877.230.7555
TTY: 711
prevea360.com
Prevea360 is underwritten by Dean Health Plan, Inc.
Prevea360 Health Plan does not discriminate on the basis of disability in the provisions of programs, services
or activities. If you need this printed material interpreted or in an alternate format, or need assistance in using
any of our services, please contact a Customer Care Specialist at 877.230.7555 (TTY: 711).
© 2016 Prevea360 Health Plan
P6034_1511