2016_P360_ETF_PlanBook - Prevea360 Health Plan

Prevea360 Health Plan does not discriminate on the basis of disability in the provision of programs, services or activities. If you
need this printed material interpreted, or in an alternative format, or need assistance in using any of our services, please contact our
Customer Care Center at 877.230.7555.
Dean Health Plan is a Qualified Health lan issuer, featuring Prevea360 plans, on the Health Insurance Marketplace.
PREVEA360 HEALTH PLAN
PO Box 28467
Prevea360 Health Plan 2016 State of Wisconsin Plans
©2015 Prevea360 Health Plan
Green Bay, WI 54324-0467
prevea360.com
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877.230.7555
TTY Users Dial 711
Prevea360 is underwritten by Dean Health Plan, Inc.
P4900_1509
2016
State of Wisconsin
Group Health
Insurance Program
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prevea360.com
Table of Contents
Get Started With Your Plan
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Discover prevea360.com
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Wellness Programs
6
The Prevea360 Provider Network
7
Understanding Your Benefit
8
Getting the Right Care
9
Using Your Plan
10
Common Insurance Terms
11
Member Rights and Responsibilities
12
Complaints, Grievances
and Appeals Process
12
Privacy and Confidentialit
13
Limitations and Exclusions
14
Welcome to
Prevea360 Health Plan
Prevea360 Health Plan is available to State of Wisconsin employees
living in northeastern Wisconsin. It is underwritten by Dean Health Plan,
so you know it’s a plan Wisconsinites have come to know and trust.
What makes Prevea360 so special is its proprietary network of hospitals,
physicians and ancillary providers that is based on Prevea Health’s
multi-specialty physician group and Hospital Sisters Health System
(HSHS) partner hospitals. These include St. Vincent’s and St. Mary’s
Hospitals in Green Bay, St. Nicholas Hospital in Sheboygan and St. Clare
Memorial Hospital in Oconto Falls, as well as other in-network hospitals
in Manitowoc and Door County. This collaboration between health care
experts, hospital partners and insurance provider as an integrated health
system leads to a better, more affordable experience for our members and
patients—one that is centered around you.
Recognized High-Quality Care
Accreditation is by the National
Committee for Quality Assurance.
NCQA is an independent, notfor-profit organization that
evaluates health plans based on
over 50 standards of care and
service to determine health plan
accreditation.
Go to the State of Wisconsin Employees page of our
website to access your policy’s specific benefits and
coverage details – prevea360.com/wi-employees.
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Getting Started with Your Plan
The best health care starts with a solid foundation. As a member of Prevea360 Health Plan, we want to help you get
the care you need as quickly and as easily as possible. Here are a few steps to help facilitate a seamless transition to
Prevea360 if you are new to us. These steps also provide helpful tips for those who are continuing their coverage with
Prevea360:
Sign Up for Member Tools
Access your plan information or health care records at any time. It’s easy – click on the Account Login in the top right corner
of prevea360.com/wi-employees and follow the simple steps to activate your online accounts. Learn more about these
dynamic tools on page 5.
Review Your Health Care Benefits
Together, the “It’s Your Choice” materials from the Wisconsin Department of Employee Trust Funds (ETF) and the “Summary
of Benefits and Coverage” documents from Prevea360 Health Plan specifically outline the benefits, services, exclusions
and limitations under your policy. The Summary reflects Prevea360 Health Plan’s specific benefits, so be sure to read both.
Access them on prevea360.com/wi-employees. Please also see etf.wi.gov.
Choose a Primary Care Physician
Choose a primary care physician (PCP) who is right for you. Go to prevea360.com/wi-employees to access our online
Provider Directory or call the Customer Care Center at 877.230.7555. Fostering an open and honest relationship with a
primary care physician you can trust is an important part of Prevea360’s integrated care model.
Transfer Your Medical Records
Once you’ve chosen a primary care physician and made an initial appointment, have your medical records sent over
from your previous clinic. Simply fill out an “Authorization to Release Protected Health Information” form, available at
prevea360.com in the Member Document Library under the For Members tab. Give it to your previous provider, and he or
she will transfer the records to your new Prevea360 provider.
Let Us Know if You Have Health Concerns
If you have a chronic health condition or have a complex health care need, we encourage you to take advantage of our
Care Management services. Visit prevea360.com/caremanagement or call the Customer Care Center at 877.230.7555 for
more information.
Participate in Health and Wellness Programs
Living Healthy, Prevea360’s comprehensive wellness program, is designed to support your overall well-being and help you
make healthy choices. The Living Healthy program can help you quit tobacco, get you discounts at local health clubs, help
you manage chronic health conditions and reward you for participating in the State of Wisconsin’s Well Wisconsin program.
Here When You Need Us
We’re here to help make Prevea360 Health Plan coverage as clear and understandable as possible because we know
insurance can be confusing at times. That’s why we’ve staffed the Prevea360 Customer Care Center with experienced
and knowledgeable Customer Care Specialists, ready to answer your questions. Phone calls aren’t the only option,
either. You may also send an email message. Whatever works for you, we’re here to help.
Go Online
Call Customer Care
Visit prevea360.com and
fill out the Contact Us form.
877.230.7555 (TTY users dial 711)
Monday through Thursday 7:30 a.m. to 5 p.m.
Friday 8 a.m. to 4:30 p.m.
Prevea Care After Hours*
If you’re not sure if you need to see a doctor, or you have a pressing health question, experienced registered nurses
at Prevea Care After Hours are always available to answer your questions. Call 24 hours a day, 365 days a year at
920.496.4700 or toll free at 888.277.3832.
* NOTE: Due to licensing regulations, Prevea Care After Hours triage services are only available to Wisconsin residents.
Discover prevea360.com
On our website, prevea360.com, State employees can find everything they need to manage their health care and coverage in one
location. Health care and coverage can be a confusing subject. We want to take the stress out of finding the information you need.
Find an Insurance Plan, Find a Provider,
Find a Pharmacy
MyPrevea
Convenient home page buttons give you easy access to plan details
and the online Provider Directory and Pharmacy Directory.
MyPrevea is a free service for Prevea Health patients, providing
members with online access to information in their personal and
family health records—anytime.
For Members
With MyPrevea you can:
The State of WI Members section of For Members is especially
tailored for you. Find plan information and learn more about processes
and coverage definitions in the Using Your Plan section. Get your
questions answered in our Frequently Asked Questions.
Your Account
The Account Login section of the site is where members, providers
and agents can connect to our online resources. As a member and
patient, register with a Member Profile (as a Prevea360 Health Plan
member) and MyPrevea account (as a Prevea Health patient) to start
managing your health and coverage details online.
Member Profile
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Communicate with a physician and health care team through
secure messaging
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Get real-time lab and test results
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Request prescription refills
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View current medical records
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Schedule future medical appointments and review past visits
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Pay medical bills online
Access your plan information anytime!
The online Member Profile is a complete member portal. It provides
access to plan information and tools to help manage your health care
coverage all in one place, at any time.
Once you register, the online member tools allow you to:
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Review your coverage benefits
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Change your primary care physician
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Manage subscriber and dependent information
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Request ID cards
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Review claims information and status
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Check the status of prior authorizations
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Take Charge of Your Wellness
Prevea360 Health Plan is proud to partner with the State of Wisconsin’s Group Health Insurance program’s Well
Wisconsin program. Well Wisconsin is designed to help you increase your awareness of current and future health risks
– while saving you money in the process. If you choose to participate in and complete the Well Wisconsin program,
you’ll earn a $150 reward from Prevea360 Health Plan!
All adults enrolled in State of Wisconsin insurance are eligible to participate in the Well Wisconsin program. Your
spouse/partner and adult dependents age 18 or older may complete the program and earn their own reward from
Prevea360*. If you have questions about your eligibility for this program, please contact your Human Resources or
Benefits department.
Completing the Well Wisconsin program is easy – simply follow these two steps:
1. Take a Wellness Assessment
Get up-to-date testing results on your height and weight, cholesterol level, glucose measurement, and blood
pressure. You can do this by visiting your primary care physician or attending an on-site screening event. Visit
wellwisconsin.wi.gov and click on the Well Wisconsin Calendar to see times and locations of scheduled events.
You’ll need your wellness assessment results for step 2, so keep them handy.
2. Complete your Well-Being Assessment online
Prevea360’s Well-Being Assessment (WBA) is an easy survey that combines your answers to lifestyle questions with
the basic screening measures from your wellness assessment (step 1) to evaluate your overall health and well-being.
a. Go to prevea360.com/wi-employees and select Health and Wellness under “2015 Plan and Enrollment
Information.” Click Complete a Biometric Screening AND our Online Well-Being Assessment (WBA) to earn a
$150 incentive award!
b. Click the Take me to My Online WBA and Rewards Center button to complete the survey. And don’t forget to
redeem your points. It’s like checking for an online purchase.
Living Healthy
Prevea360 Health Plan’s Living Healthy wellness program provides tools and resources to identify and reduce
preventable health risks, while helping you make healthy lifestyle decisions. In addition to the Well-Being
Assessment, Prevea360 offers resources to help you quit smoking and manage any complex and chronic conditions.
Check out prevea360.com/wi-employees and scroll down to the Health & Wellness section to learn more.
Each adult, spouse and dependent child over age 18 can earn $150 per year for completing
the Well Wisconsin program!
*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.
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Prevea360 Health Plan 2016 State of Wisconsin Plans
The Prevea360 Network
Our network offers expertise in nearly every specialty, with advanced specialties that
are not found anywhere else in northeast Wisconsin. Prevea providers offer care at
18 locations plus their partner HSHS hospitals, including St. Vincent’s and
St. Mary’s Hospitals in Green Bay, St. Nicholas Hospital in Sheboygan
and St. Clare Memorial Hospital in Oconto Falls, as well as other
in-network hospitals in Manitowoc and Door County.
To find a provider or specialist, see prevea360.com/wi-employees
for the online provider directory.
»» To search the directory by name, location or specialty, select
Online Provider Directory. A provider’s name will display
“Accepting New Patients” when available.
»» To download an electronic copy of the directory, select
Printable Provider Directory.
»» You may also call our Customer Care Center at 877.230.7555 to
request a copy to be mailed to you.
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Understanding Your Benefits
The State of Wisconsin HMO Plan from Prevea360 Health Plan is a network-based plan. That means your primary care
physician (PCP) from our network oversees all aspects of your health care needs and emphasizes preventive care to keep you
as healthy as possible. Please refer to the State of Wisconsin Group Health Insurance program’s “It’s Your Choice” materials
and your “Summary of Benefits and Coverage” from Prevea360 for details.
Claims and Payment
FILING CLAIMS
Time is valuable to all of us; that’s why Prevea360 Health Plan minimizes the amount of paperwork required for our
members. In most cases, claims are submitted directly to Prevea360 Health Plan by providers or clinic staff. 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, please be sure to follow these guidelines:
1.
Send an itemized bill from the provider of services. 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.
2.
Send the bill within 60 days of receiving the services to:
Prevea360 Health Plan
Attn: Claims Department
P.O. Box 56099
Madison, WI 53705
EXPLANATION OF BENEFITS (EOB)
The EOB contains important information including the total amount charged, the amount paid by Prevea360 Health Plan,
and the amount that is your (the member’s) responsibility. You may access all of your EOBs online at any time through your
online Member Profile (see page 5). Remember, an EOB is not a bill.
PREVEA360.COM/ WI-EMPLOYEES
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Provider Listings
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Department of Employee Trust Funds Plan Information
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Prevea360 Health Plan Communication – copies of letters and other correspondence sent
to all State of Wisconsin Employees
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Prevea360 Health Plan 2016 State of Wisconsin Plans
Getting the Right Care
Emergency Care
Primary Care
Urgent Care
You may be wondering why we stress the importance of selecting a primary care physician (or location) within the Prevea360
Health Plan network when you enroll. It’s because we emphasize a proactive, preventive approach to care—one in which a
primary care physician oversees all aspects of your health care needs. This keeps you and your family well and decreases the
duplication of services. Your primary care physician should be your first choice for care whenever possible. But know that
when a more immediate need arises, you do have other options.
Urgent and Emergency Care
If immediate care is needed, visit urgent care. Urgent care is designed to treat medical problems that require attention sooner
than a regular office visit, but are not serious enough to warrant a visit to an emergency department. Urgent care sites are also
generally open on evenings and weekends.
For critical illness or injury, seek emergency care. Though urgent care centers are convenient and a good option for some
illnesses and injuries, more serious symptoms need immediate care at an emergency department. Dial 911 if you think a
health problem is life threatening or could worsen on the way to the hospital.
Out-of-Area Care
With Prevea360 Health Plan, there’s no need to take health insurance worries on vacation. Both urgent and emergency
care are covered by Prevea360 if you or your covered family member are unable to return to the service area for immediate
treatment. It’s also a good idea to familiarize yourself with the types of ailments that can be treated as urgent care vs.
emergency care. Visit prevea360.com/rightcare for details.
Not sure if you need urgent or emergency care? Call Prevea Care After Hours at
920.496.4700 or 888.277.3832, or visit prevea360.com/rightcare for help.
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Using Your Plan
Prior Authorization
As you navigate your health care, it’s important to note that there are certain medical services or provider visits that
will require prior authorization by Prevea360 Health Plan. These authorizations are required so our Medical Affairs
team can make sure you are getting the appropriate care. A good rule to remember is that any time you seek services
with an out-of-network provider, you will need to obtain a prior authorization.
Utilization Management
When you need to discuss issues or have questions related to the requirement of an authorization for a particular
service, Prevea360 Health Plan is here to help. Contact the Customer Care Center at 877.230.7555 (TTY users dial
711) and you will be connected to the Utilization Management department. This department ensures you receive the
appropriate and necessary care for your condition.
Utilization Management staff members are available Monday through Friday, 8:00 a.m. to 4:30 p.m. If you have
an urgent need outside of those hours, please leave a message with the Customer Care Center and your call will be
returned within one business day.
New Medical Technology
Each year Prevea360 Health Plan evaluates new medical technology and reviews existing technology to determine if
any changes or updates are needed to guidelines outlining appropriate use. During this process, we review requests for
ongoing care or treatment recommendations for all Utilization Management decisions, including medical, behavioral
health care, pharmaceuticals and medical devices.
Prevea360 Health Plan follows the review process set by the National Commission for Quality Assurance (NCQA).
Based upon the results of the technology assessment, we will draft or revise medical policies if necessary.
Language Assistance
Translating or interpreting services are available for those members who need them, including
sign language for members who are hearing impaired. These services are free.
800.279.1301 (TTY: 711)
800.279.1301 (TTY: 711)
800.279.1301 (TTY: 711)
800.279.1301 (TTY: 711)
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Prevea360 Health Plan 2016 State of Wisconsin Plans
Common Insurance Terms
Allowed amount – The maximum amount on which payment
is based for a health plan’s covered health care services.
Annual maximum out-of-pocket – The maximum amount
a member could pay out-of-pocket for covered health care
services in a plan year before the plan would pay 100
percent of the cost of covered services. The maximum does
not include premium payments.
Health Savings Account (HSA) – A medical savings
account available to taxpayers who are enrolled in a High
Deductible Health Plan. The funds contributed to the account
aren’t subject to federal income tax at the time of deposit.
Funds must be used to pay for qualified medical expenses.
Unlike a Flexible Spending Account (FSA), funds roll over
year to year if you don’t spend them.
Individual mandate – All individuals, with certain exceptions,
are required to maintain minimum essential health coverage
under the Affordable Care Act provisions.
Benefit maximum – A benefit maximum is a limit on a
covered service. A service may be limited by duration or
number of visits – and if not an Essential Health Benefit, by
dollar limit. To review your benefit maximums please refer to
your member certificate.
Coinsurance – 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% would be $20.
Prevea360 pays the rest of the allowed amount.
Copay – 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.
Deductible – The amount you owe for covered services
before the plan begins to pay. For example, if your deductible
is $1,000, Prevea360 Health Plan won’t pay anything for
covered services subject to the deductible until you’ve met
your $1,000. Not all services are subject to the deductible,
such as preventive services.
In-network providers – Refers to physicians, hospitals
or other health care providers who are contracted with
Prevea360 Health Plan.
Out-of-network providers – Refers to physicians, hospitals
or other health care providers who are not contracted with
Prevea360 Health Plan, which could result in a greater cost
for services for you.
Pre-existing condition – A health problem you had
before the date that new health coverage starts. Under the
Affordable Care Act, insurers may no longer impose benefit
limitations or exclusions due to a pre-existing condition.
Preventive care – Routine health care that includes
screenings, check-ups and patient counseling to prevent
illnesses, disease or other health problems.
Prior authorization – Approval from a health plan that
may be required before you receive services or fill a
prescription in order for the service or prescription to be
covered by your plan.
Essential Health Benefits (EHB) – Essential Health Benefits
consist of 10 health care benefit categories. Plans that cover
EHB may not put an annual or lifetime dollar limit on the
amount of EHB.
Formulary – A list of prescription drugs covered by an
insurance plan offering prescription drug benefits. Also
called a drug list. Normally a formulary will also tell you what
tier (or cost-sharing level) a particular drug will be in.
Guaranteed issue – A requirement that health plans must
allow you to enroll for coverage regardless of health status,
age, gender or any other factors that might predict the future
use of health services.
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Member Rights & Responsibilities
Prevea360 Health Plan members deserve the best service and health care possible. Prevea360 is committed to
maintaining a mutually respectful relationship with its members. To promote effective health care, Prevea360 clearly
states its expectations for the rights and responsibilities of its members, to foster cooperation among members,
practitioners and Prevea360.
Members have the right to:
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Be treated with respect and recognition of their dignity and right to privacy.
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Receive a listing of PRevea360 Health Plan participating practitioners in order to choose a Primary Care Physician.
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Present a question or complaint or grievance to Prevea360, about the organization or the care it provides, without fear
of discrimination or repercussion.
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Receive information on procedures and policies regarding their health care benefits.
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Timely responses to requests regarding their health care plan.
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Request information regarding Advance Directives.
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Participate with practitioners in making decisions about their health care.
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A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or
benefit coverage.
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Receive information about the organization, its services, its practitioners and providers, and members’ rights
and responsibilities.
Members have the responsibility to:
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Read and understand the materials provided by Prevea360 Health Plan concerning their health care benefits.
Prevea360 encourages members to contact Prevea360 if they have any questions.
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Present their ID card in order to identify themselves as Prevea360 members before receiving health care services.
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Notify Prevea360 Health Plan of any enrollment status changes such as family size or address.
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Supply information (to the extent possible) that the organization and its practitioners and providers need in order to
provide care.
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Follow plans and instructions for care that they have agreed on with their practitioners.
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Understand their health problems and participate in developing mutually agreed upon treatment goals to the
degree possible.
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Fulfill financial obligations as they relate to any copays, deductibles and/or premiums as outlined in your policy.
Complaints, Grievances and Appeals Process
We know that at times you may have questions and concerns about benefits, claims or services you have received from Prevea360
Health Plan. Sharing your concerns will help us to identify areas of improvement or clarification needed in our processes or
documents as well as help clear up areas of confusion with your benefits or coverage. When a question or concern arises, we
encourage you to reach out to our Customer Care Center at 877.230.7555. 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 or contact the Customer Care Center at 877.230.7555 with any questions about the process.
As a member of the State of Wisconsin Group Health Insurance Program, you also have the right to request an administrative review
through ETF if an Independent Review Organization has not rendered a decision on your grievance that is final and binding. Refer to
your “It’s Your Choice Reference Guide” for details on this process.
The effective date of these notices is August 4, 2014.
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Prevea360 Health Plan 2016 State of Wisconsin Plans
Privacy & 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.
What Types of Nonpublic Personal Information
Does Prevea360 Collect About You?
We collect a variety of nonpublic personal information
needed to administer health insurance coverage and benefits.
We collect this information about you from some of the
following sources:
• Information we receive directly or indirectly from your
applications, surveys, and other forms, in writing, in
person, by telephone, and 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 requests, and appeal and grievance information.
•
•
•
•
Information you authorize us to collect from others.
How does Prevea360 protect 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 and state regulations to protect 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 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.
use or disclose your health information to determine
your eligibility for plan benefits, obtain premiums and
collect payment from third parties such as other health
plans or providers for the care you receive.
Health Care Operations: We may use and disclose your
health information to carry out necessary insurancerelated activities and to provide coverage and services to
you. Health care operations include such activities as:
underwriting, premium rating, case management and
care coordination, fraud and abuse detection programs,
medical reviews, business planning and development
and general administrative activities such as customer
service efforts and resolution of internal grievances.
Treatment Alternatives: We may contact you or your
health care providers with information about treatment
alternatives and other related functions that may be of
interest to you.
Distributing Health-Related Benefits and Services: We
may use or disclose your health information to provide
information on health related benefits and services that
may be of interest to you.
Disclosure to Plan Sponsors: If applicable, we may
disclose certain health information to the sponsor of
your group health plan for purposes of administering
benefits under the plan or to determine whether you are
participating in the health plan.
Summary Statement of Your Health
Information Rights
All requests to exercise the rights listed below must be
submitted in writing to the Privacy Officer, or you can call the
Prevea360 Health Plan Customer Care Center to request the
appropriate form to complete. You have the right to:
• Request restrictions on certain uses and disclosures of
your health information.
• Receive your health information through a reasonable
alternative means or at an alternative location.
• Inspect and copy certain health information about you.
• Request that Prevea360 amend health information held
by Prevea360 that you believe is incorrect or incomplete.
• Receive a list of certain disclosures of your
health information.
When Prevea360 May Use or Disclose Your
Health Information
We will not disclose your nonpublic personal information
unless we are allowed or required by law to do so. If required
by law, we will obtain your authorization prior to using or
disclosing your health information. You may revoke this
authorization in writing at any time.
The following categories describe the ways that Prevea360
may use and disclose your nonpublic personal information.
In carrying out the functions listed below, Prevea360 may
transmit your nonpublic personal information to people
or organizations outside of Prevea360 as allowed under
the law. When Prevea360 transmits or releases nonpublic
personal information to another organization, Prevea360
requires the other organization to protect your information
from unauthorized and inappropriate use or disclosure. Not
every use or disclosure we might make will be listed.
• Payment Functions: We may use or disclose your
health information to make or collect payment for
treatment or services you receive. For example, we may
Questions?
If you would like a paper copy of the Prevea360 Health
Plan Official Notice of Privacy Practices, want more
information about our privacy practices, have questions
about any part of this notice, or you have a complaint
regarding our privacy practices, please contact the Privacy
Officer at the following address, or call the Prevea360
Customer Care Center at 877.230.7555: Privacy Officer,
PO Box 56099, Madison, Wisconsin 53705.
The effective date of this notice is August 4, 2014.
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Limitations & Exclusions
All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your plan. The following list is not exhaustive and
may vary based on your plan. For a complete listing refer to your plan.
such as learning/developmental disabilities, communication
delays, perceptual disorders, mental retardation, behavioral
disorders, hyperactivity, attention deficit disorders, minimal
brain dysfunction, sensory deficits, multiple handicaps,
and motor dysfunction. (Note: Mandated benefits for autism
spectrum disorders under Wis. Stat. § 632.895 (12m) limit this
exclusion.)
• Physical fitness or exercise programs.
• Biofeedback, except that provided by a physical therapist for
treatment of headaches and spastic torticollis.
• Massage therapy.
5. Oral Surgery/Dental Services/Extraction and Replacement Because of
Accidental Injury
• All services performed by dentists and other dental services,
including all orthodontic services, except those specifically listed
in the Benefits and Services section or which would be covered
if it was performed by a physician and is within the scope of
the dentist’s license. This includes, but is not limited to, dental
implants; shortening or lengthening of the mandible or maxillae;
correction of malocclusion; and hospitalization costs for services
not specifically listed in the Benefits and Services section. (Note:
Mandated TMJ benefits under Wis. Stat. § 632.895 (11) may
limit this exclusion.)
• All periodontics procedures, except gingivectomy surgery as
listed in the Benefits and Services section.
• All oral surgical procedures not specifically listed in the Benefits
and Services section.
6. Transplants
• Transplants and all related services, except those listed as
covered procedures.
• Services in connection with covered transplants unless Prior
Authorized by the Health Plan.
• Retransplantation or any other costs related to a failed transplant
that is otherwise covered under the global fee. Only one
transplant per organ per Participant per Health Plan is covered
during the lifetime of the policy, except as required for treatment
of kidney disease.
• Purchase price of bone marrow, organ or tissue that is sold
rather than donated.
• All separately billed donor-related services, except for kidney
transplants.
• Non-human organ transplants or artificial organs.
7. Reproductive Services
• Infertility services which are not for treatment of Illness or Injury
(i.e., that are for the purpose of achieving pregnancy). The
diagnosis of infertility alone does not constitute an Illness.
• Reversal of voluntary sterilization procedures and related
procedures when performed for the purpose of restoring fertility.
• Services for storage or processing of semen (sperm);
donor sperm.
• Harvesting of eggs and their cryopreservation.
• Artificial insemination or fertilization methods including, but
not limited to, in vivo fertilization, in vitro fertilization, embryo
A. Exclusions
1. Surgical Services
• Procedures, services, and supplies related to surgery and sex
hormones associated with gender reassignment.
• Any surgical treatment or hospitalization for the treatment
of obesity, including morbid obesity or as treatment for the
Comorbidities of obesity, for example, gastroesophageal reflux
disease. This includes, but is not limited to, stomach-limiting
and bypass procedures.
• Keratorefractive eye surgery, including but not limited to,
tangential or radial keratotomy, or laser surgeries for the
correction of vision.
2. Medical Services
• Examination and any other services (for example, blood tests)
for informational purposes requested by third parties. Examples
are physical exams for employment, licensing, insurance,
marriage, adoption, participation in athletics, functional capacity
examinations or evaluations, or examinations or treatment
ordered by a court, unless otherwise covered as stated in the
Benefits and Services section.
• Expenses for medical reports, including preparation and
presentation. Services rendered (a) in 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)
in the cutting, trimming or other nonoperative partial removal of
toenails; or (c) treatment of flexible flat feet. This exclusion does
not apply when services are performed by a Plan Provider to treat
a metabolic or peripheral disease or a skin or tissue infection.
• Weight loss programs including dietary and nutritional treatment
in connection with obesity. This does not include Nutritional
Counseling as provided in the Benefits and Services section
• Work-related preventive treatment (for example, Hepatitis
vaccinations, Rabies vaccinations, small pox vaccinations, etc.).
• Services of a blood donor. Medically Necessary autologous blood
donations are not considered to be Services of a blood donor.
• Genetic testing and/or genetic counseling services, unless
Medically Necessary to diagnose or treat an existing illness.
3. Ambulance Services
• Ambulance service, except as outlined in the Benefits and
Services section, unless authorized by the Health Plan.
• Charges for, or in connection with, travel, except for ambulance
transportation as outlined in the Benefits and Services section.
4. Therapies
• Vocational rehabilitation including work hardening programs.
• Except for services covered under the HABILITATION SERVICES
therapies benefit, therapies, as determined by the Health Plan, for
the evaluation, diagnosis or treatment of educational problems.
Some examples of the type of assessments and therapies that
are not covered are: educational programs, developmental
and neuro-educational testing and treatment, second opinions
on school or educational assessments of any kind, including
physical therapy, speech therapy, occupational therapy and
all hearing treatments for the conditions listed herein. These
therapies that are excluded may be used to treat conditions
14
Prevea360 Health Plan 2016 State of Wisconsin Plans
transfer, gamete intra fallopian transfer (GIFT) and similar
procedures, and related Hospital, professional and diagnostic
services and medications that are incidental to such insemination
or fertilization methods.
• Surrogate mother services.
• Maternity services received out of the Plan Service Area one
month prior to the estimated due date, unless Prior Authorized
(Prior Authorization will be granted only if the situation is out of
the Participant’s control, for example, family emergency).
• Amniocentesis or chorionic villi sampling (CVS) solely for sex
determination.
8. Hospital Inpatient Services
• Take home drugs and supplies dispensed at the time of discharge,
which can reasonably be purchased on an outpatient basis.
• Hospital stays, which are extended for reasons other than Medical
Necessity, limited to lack of transportation, lack of caregiver,
inclement weather and other, like reasons.
• A continued Hospital stay, if the attending physician has documented
that care could effectively be provided in a less acute care setting, for
example, Skilled Nursing Facility.
9. Mental Health Services/Alcohol and Drug Abuse
• Hypnotherapy.
• Marriage counseling.
• Residential care except residential care for Alcohol and Drug
Abuse and transitional care as required byWis. Stat. § 632.89
and Wis. Admin Code § INS 3.37.
• Biofeedback.
10. Durable Medical or Diabetic Equipment and Supplies
• All Durable Medical Equipment purchases or rentals unless Prior
Authorized as required by the Health Plan.
• Repairs and replacement of Durable Medical Equipment/supplies
unless authorized by the Health Plan.
• Medical Supplies and Durable Medical Equipment for comfort,
personal hygiene and convenience items such as, but not
limited to, wigs, hair prostheses, air conditioners, air cleaners,
humidifiers; or physical fitness equipment, physician’s
equipment; disposable supplies; alternative communication
devices (for example, electronic keyboard for a hearing
impairment); and self-help devices intended to support the
essentials of daily living, including, but not limited to, shower
chairs and reaches, and other equipment designed to position or
transfer patients for convenience and/or safety reasons.
• Home testing and monitoring supplies and related equipment
except those used in connection with the treatment of diabetes or
infant apnea or as Prior Authorized by the Health Plan.
• Equipment, models or devices that have features over and above
that which are Medically Necessary for the Participant will be
limited to the standard model as determined by the Health Plan.
This includes the upgrade of equipment, models or devices
to better or newer technology when the existing equipment,
models or devices are sufficient and there is no change in the
Participant’s condition nor is the existing equipment, models or
devices in need of repair or replacement.
• Motor vehicles (for example, cars, vans) or customization of
vehicles, lifts for wheel chairs and scooters, and stair lifts.
• Customization of buildings for accommodation (for example,
wheelchair ramps).
eplacement or repair of Durable Medical Equipment/supplies
R
damaged or destroyed by the Participant, lost or stolen.
11. Outpatient Prescription Drugs- Administered by the Pharmacy Benefit
Manager (PBM)
• Charges for supplies and medicines with or without a doctor’s
prescription, unless otherwise specifically covered.
• Charges for prescription drugs which require Prior Authorization
unless approved by the PBM.
• Charges for cosmetic drug treatments such as Retin-A, Rogaine,
or their medical equivalent.
• Any FDA medications approved for weight loss (for example,
appetite suppressants, Xenical).
• Anorexic agents.
• Non-FDA approved prescriptions, including compounded
estrogen, progesterone or testosterone products, except as
authorized by the PBM.
• All over-the-counter drug items, except those designated as
covered by the PBM.
• Unit dose medication, including bubble pack or pre-packaged
medications, except for medications that are unavailable in any
other dose or packaging.
• Charges for injectable medications, except for Self-Administered
Injectable medications.
• Charges for supplies and medicines purchased from a NonParticipating Pharmacy, except when Emergency or Urgent Care
is required.
• Drugs recently approved by the FDA may be excluded until
reviewed and approved by the PBM’s Pharmacy and Therapeutics
Committee, which determines the therapeutic advantage of the
drug and the medically appropriate application.
• Infertility and fertility medications.
• Charges for medications obtained through a discount program or
over the Internet, unless Prior Authorized by the PBM.
• Charges to replace spilled, stolen or lost prescription drugs.
12. General
• Any additional exclusion as described in the Schedule of Benefits.
• Except for benefits payable under Medicare Part D, services to the
extent the Participant is eligible for all other Medicare benefits,
regardless of whether or not the Participant is actually enrolled in
Medicare. This exclusion only applies if the Participant enrolled in
Medicare coordinated coverage does not enroll in Medicare Part B
when it is first available as the primary payor or who subsequently
cancels Medicare coverage.
• Treatment, services and supplies for which the Participant: (a) has
no obligation to pay or which would be furnished to a Participant
without charge; (b) would be entitled to have furnished or paid
for, fully or partially, under any law, regulation or agency of any
government; or (c) would be entitled, or would be entitled if
enrolled, to have furnished or paid for under any voluntary medical
benefit or insurance plan established by any government; if this
contract was not in effect.
• Injury or Illness caused by: (a) Atomic or thermonuclear explosion
or resulting radiation; or (b) any type of military action, friendly or
hostile. Acts of domestic terrorism do not constitute military action.
• Treatment, services and supplies for any Injury or Illness as the
result of war, declared or undeclared, enemy action or action of
Armed Forces of the United States, or any state of the United States,
or its Allies, or while serving in the Armed Forces of any country.
•
15
prevea360.com
Limitations & Exclusions (ctd.)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
certain organ transplants. In general, any service considered to
be Experimental, except drugs for treatment of an HIV infection, as
required by Wis. Stat. § 632.895 (9) and routine care administered
in a cancer clinical trial as required by Wis. Stat. § 632.87 (6).
• Services provided by members of the Subscriber’s Immediate
Family or any person residing with the Subscriber.
• Services, including non-physician services, provided by Non-Plan
Providers. Exceptions to this exclusion:
• On written Referral by Plan Provider with the prior written
authorization of the Health Plan
• Emergencies in the Service Area when the Primary Care
Provider or another Plan Provider cannot be reached
• Emergency or Urgent Care services outside the Service Area.
Non-urgent follow-up care requires Prior Authorization from
the Health Plan.
• Services of a specialist without a Plan Provider’s written Referral,
except in an Emergency or by written Prior Authorization of the
Health Plan. Any Hospital or medical care or service not provided
for in this document unless authorized by the Health Plan.
• Coma stimulation programs.
• Orthoptics (Eye exercise training) except for two sessions as
Medically Necessary per lifetime. The first session for training, the
second for follow-up.
• Any diet control program, treatment, or supply for weight reduction.
• Food or food supplements except when provided during a covered
outpatient or inpatient Confinement.
• Services to the extent a Participant receives or is entitled to receive,
any benefits, settlement, award or damages for any reason of,
or following any claim under, any Worker’s Compensation Act,
employer’s liability insurance plan or similar law or act. Entitled
means You are actually insured under Worker’s Compensation.
• Services related to an Injury that was self-inflicted for the purpose of
receiving Health Plan and/or PBM Benefits.
• Charges directly related to a non-covered service, such as
hospitalization charges, except when a complication results from
the non-covered service that could not be reasonably expected
and the complication requires Medically Necessary treatment that
is performed by a Plan Provider or Prior Authorized by the Health
Plan. The treatment of the complication must be a covered benefit
of the Health Plan and PBM. Non-covered services do not include
any treatment or service that was covered and paid for under any
plan in our program.
• Treatment, services and supplies for cosmetic or beautifying
purposes, except when associated with a covered service to correct
a functional impairment related to Congenital bodily disorders
or conditions or when associated with covered reconstructive
surgery due to an Illness or accidental Injury (including
subsequent removal of a prosthetic device that was related to such
reconstructive surgery). Psychological reasons do not represent a
medical/surgical necessity.
• Any smoking cessation program, treatment, or supply that is not
specifically covered in the Benefits and Services section.
• Any charges for, or in connection with, travel. This includes but is
not limited to meals, lodging and transportation. An exception is
Emergency ambulance transportation.
• Sexual counseling services related to infertility and sexual
transformation.
• Services that a child’s school is legally obligated to provide,
whether or not the school actually provides the services and
whether or not You choose to use those services.
T reatment, services and supplies furnished by the U.S. Veterans
Administration (VA), except for such treatment, services and
supplies for which under the policy the Health Plan and/or PBM
is the primary payor and the VA is the secondary payor under
applicable federal law. Benefits are not coordinated with the VA
unless specific federal law requires such coordination.
Services for holistic medicine, including homeopathic medicine,
or other programs with an objective to provide complete personal
fulfillment.
Treatment, services or supplies used in educational or vocational
training.
Treatment or service in connection with any Illness or Injury caused
by a Participant (a) engaging in an illegal occupation or (b)
commission of, or attempt to commit, a felony.
Maintenance Care.
Care, including treatment, services, and supplies, provided to assist
with activities of daily living (ADL).
Personal comfort or convenience items or services such as
in-Hospital television, telephone, private room, housekeeping,
shopping, homemaker services, and meal preparation services as
part of home health care.
Charges for injectable medications administered in a nursing home
when the nursing home stay is not covered by the plan.
Custodial, nursing facility (except skilled), or domiciliary care. This
includes community reentry programs.
Expenses incurred prior to the coverage Effective Date in the
Health Plan and/or PBM, or services received after the Health
Plan and/or PBM coverage or eligibility terminates. Except
when a Participant’s coverage terminates because of Subscriber
cancellation or nonpayment of premium, benefits shall continue
to the Participant if he or she is Confined as an inpatient on the
coverage termination date but only until the attending physician
determines that Confinement is no longer Medically Necessary; the
contract maximum is reached; the end of 12 months after the date
of termination; or Confinement ceases, whichever occurs first. If the
termination is a result of a Subscriber changing Health Plans during
a prescribed enrollment period as determined by the Board, benefits
after the Effective Date with the succeeding Health Plan will be
the responsibility of the succeeding Health Plan unless the facility
in which the Participant is confined is not part of the succeeding
Health Plan’s network. In this instance, the liability will remain with
the previous insurer.
Eyeglasses or corrective contact lenses, fitting of contact lenses,
except for the initial lens per surgical eye directly related to
cataract surgery. The incremental cost of a non-standard intracular
lens (e.g., multifocal and toric lenses) compared to a standard
monofocal intraocular lens is not covered.
Any service, treatment, procedure, equipment, drug, device or
supply which is not reasonably and Medically Necessary or not
required in accordance with accepted standards of medical,
surgical or psychiatric practice.
Charges for any missed appointment.
Experimental services, treatments, procedures, equipment, drugs,
devices or supplies, including, but not limited to: Treatment or
procedures not generally proven to be effective as determined
by the Health Plan and/or PBM following review of research
protocol and individual treatment plans; orthomolecular medicine,
acupuncture, cytotoxin testing in conjunction with allergy testing,
hair analysis except in conjunction with lead and arsenic
poisoning. Phase I, II and III protocols for cancer treatments and
16
Prevea360 Health Plan 2016 State of Wisconsin Plans
B. Limitations
1. Copayments or Coinsurance are:
• State of Wisconsin program Participants, except for retirees for
whom Medicare is the primary payor, for all services unless
otherwise required under federal and state law.
• State of Wisconsin Participants for whom Medicare is the primary
payor, and for all Participants of the Wisconsin Public Employers
program, required for, and/or limitations apply to, the following
services: Durable Medical Equipment, Prescription Drugs, Smoking
Cessation, Cochlear Implants, treatment of Temporomandibular
Disorders and care received in an emergency room.
2. Benefits are limited for the following services: Replacement of Natural
Teeth because of accidental Injury, Oral Surgery, Hospital Inpatient,
licensed Skilled Nursing Facility, Physical, Speech and Occupational
Therapy, Home Care Benefits, Transplants, Hearing Aids, and
Orthoptics.
3. Use of Non-Plan Providers and Hospitals requires prior written
approval by the Participant’s Primary Care Provider and the Health
Plan to determine medical appropriateness and whether services can
be provided by Plan Providers.
4. Major Disaster or Epidemic: If a major disaster or epidemic occurs,
Plan Providers and Hospitals render medical services (and arrange
extended care services and home health service) insofar as practical
according to their best medical judgment, within the limitation of
available facilities and personnel. This extends to the PBM and its
Participating Pharmacies. In this case, Participants may receive
covered services from Non-Plan Providers and/or Non-Participating
Pharmacies.
5. Circumstances Beyond the Health Plan’s and/or PBM’s Control:
If, due to circumstances not reasonably within the control of the
Health Plan and/or PBM, such as a complete or partial insurrection,
labor disputes not within the control of the Health Plan and/or PBM,
disability of a significant part of Hospital or medical group personnel
or similar causes, the rendition or provision of services and other
benefits covered hereunder is delayed or rendered impractical, the
Health Plan, Plan Providers and/ or PBM will use their best efforts to
provide services and other benefits covered hereunder. In this case,
Participants may receive covered services from Non-Plan Providers
and/or Non-Participating Pharmacies.
6. Speech and Hearing Screening Examinations: Limited to the routine
screening tests performed by a Plan Provider for determining the need
for correction.
7. Outpatient Physical, Occupational, Speech and Rehabilitation Therapy:
These therapies are benefits only for treatment of those conditions
which, in the judgment of the attending physicians, are expected
to yield significant patient improvement within two months after the
beginning of treatment.
8. Only one transplant per organ per Participant per Health Plan is
covered during the lifetime of the policy, except as required for
treatment of kidney disease.
The effective date of this notice is January 1, 2015.
17
prevea360.com
Coverage Centered Around You
Prevea360 offers a comprehensive network of hospitals, providers and specialty physicians throughout Northeastern
Wisconsin. With hundreds of providers spanning Green Bay and the surrounding areas, Prevea360 provides you with
many choices for accessing care near your home or workplace. No matter your health care need, there is a Prevea360
provider to help.
Washington Island
Mountain
Fish Creek
Marinette
Suring
Lena
Gillett
Oconto
Oconto Falls
Sturgeon Bay
Pulaski
Seymour
Algoma
Green Bay
Luxemburg
De Pere
Go to
prevea360.com
Two Rivers
Manitowoc
to view the most up-to-date
providers and locations.
Primary care location
Primary & urgent care location
1. Go to prevea360.com/doctors.
2. Select your health plan type in the
drop-down menu.
3. Search by name, specialty, gender,
language and/or location.
Hospital
Plymouth
Oostburg
Sheboygan
B R OW N
DOOR
De Pere
Fish Creek
▲ Prevea East De Pere
Health Center
3860 Monroe Rd
De Pere, WI 54115
920.496.4700
● Ministry North Shore
Medical Clinic - Fish Creek
3711 Hwy 42
Fish Creek, WI 54212
920.868.3511
● Prevea West De Pere
Health Center
1686 Eisenhower Rd
De Pere, WI 54115
920.496.4700
Sturgeon Bay
▲ Ministry North Shore
Medical Clinic - Sturgeon Bay
323 S 18th Ave
Sturgeon Bay, WI 54235
920.746.0510
Green Bay
● Dousman Clinic
124 Siegler St
Green Bay, WI 54303
920.434.9661
Washington Island
● Ministry North Shore
Medical Clinic - Washington Island
910 Main Rd
Washington Island, WI 54246
920.847.2424
● Prevea Allouez Health Center
1821 S Webster Ave
Green Bay, WI 54301
920.496.4700
▲ Prevea Ashwaubenon Health Center
2502 S Ashland Ave
Green Bay, WI 54304
920.496.4700
▲ Prevea East Mason Health Center
3021 Voyager Dr
Green Bay, WI 54311
920.496.4700
▲ Prevea Howard Health Center
2793 Lineville Rd
Green Bay, WI 54313
920.496.4700
● Prevea Shawano Avenue Clinic
1727 Shawano Ave, Ste 201
Green Bay, WI 54303
920.496.4700
● Prevea St. Mary’s Health Center
1715 Dousman St
Green Bay, WI 54307
920.496.4700
▲ Prevea Washington
Street Health Center
102 N Washington St
Green Bay, WI 54301
920.496.4700
Pulaski
● Prevea Pulaski Health Center
940 S Saint Augustine St
Pulaski, WI 54162
920.822.5444
KEWAUNEE
● Ministry North Shore
Medical Clinic - Algoma
815 Jefferson St
Algoma, WI 54201
920.487.3496
● Prevea Luxemburg Health Center
101 School Creek Tr
Luxemburg, WI 54217
920.845.2351
▲ HFM Family Medicine
1650 S 41st St
Manitowoc, WI 54220
920.320.4500
● HFM Internal Medicine
& Gastroenterology
1900 Woodland Dr
Manitowoc, WI 54220
920.320.6212
● HFM Pediatrics
4303 Michigan Ave
Manitowoc, WI 54220
920.320.4300
● HFM Two Rivers Health Center
3310 45th St
Two Rivers, WI 54241
920.793.3900
M A R I N E TTE
Marinette
● Prevea Marinette Health Center
1409 Cleveland Ave
Marinette, WI 54143
888.277.3832
O C O N TO
Gillett
Lena
Luxemburg
Manitowoc
Two Rivers
● HSHS St. Clare Memorial Hospital
Prevea Gillett Health Center
340 N Green Bay Ave
Gillett, WI 54154
920.855.2823
Algoma
MA NITOWOC
● HFM Women’s Health
600 York St
Manitowoc, WI 54220
920.320.6705
● HSHS St. Clare Memorial Hospital
Prevea Lena Health Center
200 S Rosera St
Lena, WI 54139
920.829.6400
Mountain
● HSHS St. Clare Memorial Hospital
Prevea Mountain Health Center
14353 State Hwy 32/64
Mountain, WI 54149
715.276.1600
Oconto
● Prevea Oconto Health Center
620 Smith Ave
Oconto, WI 54143
920.834.4110
Suring
● HSHS St. Clare Memorial Hospital
Prevea Suring Health Center
913 E Main St
Suring, WI 54174
920.842.1147
O U TAGA M IE
Seymour
● Prevea Seymour Health Center
958 Foote St
Seymour, WI 54165
920.833.9896
S H E B OY GAN
Oostburg
● Prevea Oostburg Health Center
15 S 10th St, Ste A
Oostburg, WI 53070
920.496.4700
Plymouth
▲ Prevea Plymouth Health Center
825 Walton Dr
Plymouth, WI 53073
920.892.4322
Sheboygan
▲ Prevea Sheboygan Health Center
1411 N Taylor Dr
Sheboygan, WI 53081
888.277.3832
● Sheboygan Internal
Medicine Associates, S.C.
2920 Superior Ave
Sheboygan, WI 53081
920.452.6000
● Sheboygan Pediatrics
Associates, S.C.
2920 Superior Ave
Sheboygan, WI 53081
920.458.3331
Oconto Falls
▲ HSHS St. Clare Memorial Hospital
Prevea Oconto Falls Health Center
835 S Main St
Oconto Falls, WI 54154
920.846.8187
● Primary care location
▲ Primary & urgent care location
HOSPITALS
Green Bay
Manitowoc
Oconto Falls
Sheboygan
Sturgeon Bay
✚ Holy Family Memorial
Hospital
2300 Western Ave
Manitowoc, WI 54220
920.320.8741
✚ HSHS St. Clare
Memorial Hospital
855 S Main St
Oconto Falls, WI 54154
920.846.3444
✚ HSHS St. Nicholas
Hospital
3100 Superior Ave
Sheboygan, WI 53081
920.459.8300
✚ Ministry Door County
Medical Center
323 S 18th Ave
Sturgeon Bay, WI 54235
920.743.5566
HSHS St. Mary’s Hospital
Medical Center
1726 Shawano Ave
Green Bay, WI 54303
920.498.4200
✚ HSHS St. Vincent Hospital
835 S Van Buren St
Green Bay, WI 54301
920.433.0111
If you would like a printed copy of the provider directory, please call our Customer Care Center at 877.230.7555.
One of our friendly Customer Care Specialists would be happy to send you a printed copy. Please keep in mind that
the online directory has the most up-to-date listing of providers.