2015 Provider Directory. State of Wisconsin UW Health

Transcription

1 2015 Provider Directory State of Wisconsin UW Health

2 TM IMPORTANT CONTACT INFORMATION Read the instructions for using this directory and then complete this page after you have selected Primary Care Physicians (PCPs) for you and your family. YOUR PCP My PCP is: Clinic Name: Address: Phone: OTHER FAMILY MEMBERS PCPS Member s Name: PCP Name: Clinic Name: Address: Phone: Member s Name: PCP Name: Clinic Name: Address: Phone: The availability of and providers listed in this directory changes periodically. For the most up-to-date list of and providers, please visit ChooseUnityHealth.com, select Find a Doctor and choose State / Local UW Health as your network. If you have questions regarding the status of a practitioner or provider, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, chat with us at ChooseUnityHealth.com or call (800) , Monday through Friday, from 7 a.m. to 7 p.m. (CST). Please contact individual clinics for specific clinic hours. Practitioners and providers are independent contractors and not employees of Unity Health Plans Insurance Corporation. If you receive services from a network hospital, the hospital may arrange with physicians and other providers, who are not in Unity s network, to assist in your care. Unity encourages its network hospitals to hold these providers to Unity s standards for member billing. However, if a hospital does not require those providers to comply with Unity s standards, Unity cannot influence the manner or amounts that you may be billed by the provider. Unity 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 if you need assistance using any of our services, contact Unity Customer Service at (800) or (608) (TDD / TTY only). For printed information about hospital affiliations, medical group affiliations, board certifications, hospital accreditation, gender of each practitioner, languages spoken by practitioner as well as an explanation of each item listed above, its source, any limitations and how often this information is validated, please send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, Chat with Us at ChooseUnityHealth.com or call (800) If you need language assistance, please see the contact information below. Unity Customer Service (800) (toll-free) (608) (local) (608) (TDD / TTY only) (608) (fax) MyChart Member Advocate Web Site unitymychart.com (800) (toll-free) ChooseUnityHealth.com ChooseUnityHealth.com

3 WELCOME TO UNITY CONTENTS As a managed care organization, Unity s goal is to help its members be healthy while managing the quality and cost of their care. To do this, Unity works with a large network of providers who are committed to providing quality health care services ranging from preventive care to specialty care. This member information and provider directory will give you the information you need to Choose a Primary Care Physician (PCP) Access specialty care Understand the basics of managed care Become familiar with your health insurance benefits Be a wise health care consumer Learn how Unity Customer Service can assist you with your benefit questions In addition, Unity understands that medical terminology can be confusing. That s why we ve included a detailed glossary to explain some of the medical terminology and abbreviations used throughout this directory. Through ChooseUnityHealth.com, Unity s website for State of Wisconsin and Local Government participants, you have access to MyChart, a secure online tool where you can access benefit and claim information, receive electronic explanation of benefits (EOBs), take an online health risk assessment (HRA) and more. Plus, if you receive care from a UW Health provider you can access portions of your medical information and communicate with your health care team. Sign up for an account today at unitymychart.com. Find a Doctor, Unity s provider search function, provides the most up-to-date listing of Unity s and / or providers Wellness programs, including Unity s Fitness First and the State of Wisconsin s Well Wisconsin program, that offer incentives for making healthy lifestyle choices Health information, such as the Preventive Health Care Guideline, Unity s health management programs, including our 9 Months & More program for pregnant and post-natal women, and our chronic conditions education and support services Links to other helpful web sites, including the Department of Employee Trust Funds (ETF) and information about pharmacy and dental benefits To make the most of your health benefits, we encourage you to read through this directory. Along with your Unity Member Guide and the It s Your Choice: Decision and Reference Guides. Read on to learn more! i Welcome to Unity ii Map of UW Health Network Service Area iii Using the UW Health Network Provider Directory Primary Care Physicians (PCPs) Why choose a Primary Care Physician (PCP)? Steps to Follow to Select a PCP Tips for Selecting a PCP Changing Your PCP v Understanding Managed Care What is Managed Care? What are the Benefits of Managed Care? What is Medical Management? Complex Case Management vii Member Services Unity s Member Promise Unity Customer Service Your Unity Health Insurance Member Identification Card MyChart Unity s Web Site UW Health Provider Network ix Health and Wellness xiii Benefits What s Covered? Medical Benefits Dental Benefits State Employees Dental Benefits Local Government Participants Durable Medical Equipment Pharmacy Services Referral Request Process Procedures and Equipment Requiring Prior Authorization Behavioral Health xxii Accessing Urgent and Emergency Care Urgent Care Emergency Care Services Accessing Care Away from Home (Out-of-Area Care) xxiv Being a Wise Health Care Consumer Know Your Benefit Plan Member Rights and Responsibilities Member Confidentiality and Privacy Policies Complaint and Grievance Procedures xxvi Special Needs 1 PCPs 5 Hospitals, Surgery Centers and Urgent Care 7 Specialists 22 Glossary of Medical Terms 25 Index of Providers ChooseUnityHealth.com i

4 2015 UW Health Network Service Area For State and Local Government Participants 2015 UW Health Network clinic locations. (Does not include Black Earth and Cambridge. See State of Wisconsin Community Network directory for providers in these communities.) ii ChooseUnityHealth.com

5 U S I N G T H E U W H E A LT H N E T W O R K P R O V I D E R D I R E C T O R Y Primary Care Physicians (PCPs) All Unity members must select or be assigned a PCP at the time they enroll. Each member of your family may have a different PCP, from your selected network, to best suit his or her health care needs. There are seven types of physicians that can serve as PCPs for Unity members Family Practice Physician (FP) Family Practice with Obstetrics Physician (FP / OB) General Practice Physician (GP) Geriatric Physician (Ger) Internal Medicine Physician (IM) Pediatrician (Ped) OB / GYN Physician (OB / GYN) Each PCP listed in this directory has an abbreviation behind his / her name indicating his / her PCP type. These abbreviations will assist you in selecting PCPs that best meet the individual needs of your family members. Refer to the glossary at the end of this director y for more information on each PCP type. You ll also find listed in the PCP section of this directory who have other abbreviations behind their name (NP, PA, PA-C, CPNP, etc). While you may not select any of these as your PCP, they are available for physical exams, urgent or problem visits, and follow-up of ongoing health care. When calling your clinic for an appointment, keep in mind that you may be able to see a Nurse Practitioner (NP) or Physician Assistant (PA) instead of waiting for an appointment with your PCP. Why Choose a Primary Care Physician (PCP)? A PCP is a physician who works with you to manage your health care. A PCP helps ensure you receive continuous, quality care in an efficient, cost effective manner. Your PCP coordinates your medical care through Unity s network of specialty. To effectively manage your care and help you reach an optimal level of health, it s beneficial for you to have a strong working relationship with your PCP. To help you receive the best care, your PCP should Know your medical history and coordinate all of your health care needs, including working with medical / surgical specialists and behavioral health (mental health / alcohol & other drug abuse). Monitor and coordinate your care if you have a chronic medical condition such as asthma or diabetes. Recommend that you seek regular preventive health services, such as immunizations, age appropriate physical exams, and screenings. In order to choose a PCP that best meets your needs, you should consider the following Location of PCPs What location(s) best meets the needs of your family? Specialists Which specialists can you access through the PCP you select? Hospital affiliations Which hospitals can you access based on your PCP selection? iii

6 U S I N G T H E U W H E A LT H N E T W O R K P R O V I D E R D I R E C T O R Y Steps to Follow to Select a PCP Now you re ready to follow these steps to select a PCP and determine which specialists you can access Step 1 If you are currently seeing a PCP, check the index in the back of this directory to determine if your PCP is a Unity participating physician. If the physician is listed in the index, find the page number and verify that he / she is a PCP. If you currently see specialty, you should also verify that they are listed in the directory. Step 2 If you are looking for a PCP at a UW Health Clinic write Welcome Center where you put your PCP choice. You may also contact the UW Health Welcome Center at (800) Monday through Friday from 8 a.m. to 5 p.m. or you can send an to patientresources@uwmf.wisc.edu. As a new Unity member and a new UW Health patient the UW Health Welcome Center will Help you select a new Primary Care Physician Work with you to transfer your medical records from your previous health system Gather your medical history Discuss any chronic and / or preventive issues or needs you may have Help you schedule any appointments if there is an immediate need Each member of your family can have a PCP at a different clinic within the network you select. If you do not list either a PCP or a PCP clinic, Unity will assign a PCP to you. Remember, you must seek specialty care from specialty providers listed in this directory to obtain coverage under your Unity benefits. See the information on this page for changing your Unity-UW Health PCP. Step 3 Be sure to thoroughly read the first page of the PCP section in this directory. It provides information about the providers available to you. If you have questions regarding participating providers or your health benefits, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, Chat with Us online at ChooseUnityHealth.com, or call (800) , Monday through Friday 7 a.m. to 7 p.m. (CST). (See page xxii for emergency and urgent care information.) Tips for Selecting a PCP It is important to choose your PCP with care. PCPs are trained to serve as your main doctor over the long term. They provide your medical care and help you stay healthy. Look for a PCP who- Is highly recommended by your friends, family or coworkers Has the training and background that meet your needs Takes steps to help you prevent illness for example, helps you identify ways to stop smoking Has admitting privileges at the hospital of your choice Encourages you to ask questions Listens to you Explains things clearly so you can understand Treats you with respect Changing Your PCP Unity provides convenient ways to change your PCP 1. Go to unitymychart.com and log into MyChart, or 2. Contact Unity Customer Service at (800) and press 2. If you have a UW Health Clinic PCP, you can change your PCP at your clinic. Since Unity and UW Health share the same database for member and patient information, you only need to notify one of us of your change. The database is automatically updated so both of us are informed at once. For the most up-to-date list of and providers visit ChooseUnityHealth.com/findadoctor. iv ChooseUnityHealth.com

7 U N D E R S TA N D I N G M A N A G E D C A R E What is Managed Care? Managed care is designed to help keep members healthy. Managed care empowers members to seek preventive health care services and to work with their PCP to make the appropriate health care choices. Managed care consumers have rights and responsibilities to assure they receive quality care and services. This includes the right to choose a PCP, the right to privacy and confidentiality, and the responsibility for providing accurate information (see inside back cover for more information). In addition, Unity expects you as a member to be responsible for 1. Using your Unity PCP to coordinate your care 2. Contacting Unity Customer Service any time you have questions about your Unity benefits What are the Benefits of Managed Care? Unity s managed care plans promote the following Coordination of Care Your relationship with your PCP is an important one. He / she should help coordinate your health care services. Convenient Access In the Unity-UW Health network participating provider clinics are located to provide you and your family with accessible health care services in Dane County, except for the communities of Black Earth and Cambridge (providers in these communities may be found in the Unity Community Provider Network). Streamlined Administration There is very little, if any, follow-up paperwork when you seek care from a Unity participating provider. Just show your member ID card at the time of service, pay any copayment, coinsurance, or deductible (if applicable) and, in most instances, your practitioner will submit claims and prior authorizations on your behalf. Care Management Unity s doctors, nurses, and other health professionals work with your PCP to review your care and help ensure you receive medically necessary and appropriate services. Health Education and Wellness Unity partners with UW Health and a variety of community providers to offer health education classes and services to improve your health and well-being. Visit ChooseUnityHealth.com and select Health & Wellness for more information. Preventive Health Care Unity promotes preventive health care services such as age appropriate physical exams, well-child care, routine Pap tests, mammograms, and many others to help keep you and your family healthy. Unity has adopted the Preventive Health Care Guideline, based on the US Preventive Task Force, to help you plan routine care visits. This guideline includes recommenda-tions for adults, children, and pregnant women. For a copy of the guideline, visit unityhealth.com/preventive or send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, chat with us online at ChooseUnityHealth.com or call (800) v

8 U N D E R S TA N D I N G M A N A G E D C A R E What is Medical Management? Unity carefully reviews prior authorization requests and pre-certification notifications which are submitted by participating. This process of medical management, sometimes called utilization management, is conducted by experienced staff that includes registered and licensed practical nurses with the support of board certified physicians. Medical management staff work with your PCP or your treating provider to coordinate pre-service review (before care or services are delivered), concurrent review (while care or services are being provided), and post-service review (after care or services have been provided) related to your care. Unity works with participating physicians and medical management staff to help ensure decisions regarding treatment are based only on appropriateness of care and service. Unity does not reward or other individuals involved in the medical management process for issuing denials of coverage or care. Unity does not offer financial incentives or rewards for medical management decision makers to encourage decisions that result in under utilization. Complex Case Management If you have a serious or complicated medical problem, you may qualify for complex case management services. Complex case management is a process in which experienced registered nurses and licensed social workers work with both you and your doctor to coordinate, monitor, and evaluate the options and services available to best meet your health care needs. Unity s complex case management staff may become involved with you if you experience a critical event or a diagnosis for a complicated problem. Your doctor may refer you to our care team or you / and or your caregiver may contact us at (888) In addition, you may be referred for case management through Unity s medical management processes, a treating practitioner or by a referral from one of Unity s Health Management programs. vi ChooseUnityHealth.com

9 M E M B E R S E R V I C E S Unity s Member Promise Providing excellent customer service is a company-wide goal at Unity. Every employee is dedicated to helping make sure you receive the high level of service you deserve. We strive to Provide prompt and accurate member services Keep our promises and commitments to our customers Exceed our customers expectations in everything we do Unity Customer Service Unity is committed to member satisfaction. Unity Customer Service can assist you with any questions about your health benefits quickly. Unity Customer Service can be reached by sending a message through the message center within MyChart at unitymychart.com, our online chat feature at ChooseUnityHealth.com or calling (800) or (608) (TDD / TTY only). Customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. (CST). Outside of normal business hours, you may leave a voice mail message including your name, subscriber number, telephone number where you can be reached, and the best time (any time, day or night) for a customer service representative to return your call. Unity monitors and phone messages during normal business hours. We can serve you better if we have up-to-date information. If you have a change of address, please call (800) and follow the instructions regarding your changes or log into MyChart. Also, be sure to notify your Benefits / Payroll Office. Unity offers the ability to chat with a Customer Service Representative using the Internet. Chat with Us is available during Unity s normal business hours of Monday through Friday from 7 a.m. to 7 p.m. (CST). Chat makes it more convenient to receive real time answers to your questions. To chat with us go to ChooseUnityHealth.com and select the Chat with Us icon. Your Unity Health Insurance Member Identification Card Soon after enrolling in Unity you will receive two Unity identification (ID) cards. These cards identify you (the subscriber) and your covered dependents, your group number, a PCP for each family member (if applicable), and your selected provider network. Your selected network will appear as STATE / LOCAL UW HEALTH. Contact Unity Customer Service for additional or replacement ID cards, or visit the self-service forms on our website through g MyChart. y Unity U knows that privacy i c is very v important to you y u which is why your member ID number is a randomly assigned number. PLEASE READ THE IMPORTANT REMINDERS ON YOUR IDENTIFICATION CARD There is important information on the front and back of your member ID card. Do not tear it in half you will need the top and bottom portions to present at your clinic when you seek services. Always have your member ID card with you each time you access services from a participating health care provider or when calling Unity Customer Service. PCP: CLINIC NAME If you wish to change your PCP to another in the UW Health Network, notify Unity Health Insurance. You will be issued new cards with the revised information on them. Any time you are issued new cards, please destroy the old cards. Any inquiries about member ID cards can be directed to Unity Customer Service at (800) or TDD (608) ChooseUnityHealth.com vii

10 M E M B E R S E R V I C E S Signup for MyChart Today! MyChart, located at unitymychart.com, is a secure online service that provides a convenient way for you to view your Unity insurance information and portions of your UW Health medical information, if you have a UW Health medical provider. The Unity insurance information in MyChart allows you to View your benefit information Check claim status Access electronic communications including your explanation of benefits (EOB) Check eligibility for yourself and your dependents Review Prior Authorizations Request ID cards Access easy-to-use tools and resources like health risk assessments (HRA) Change your Primary Care Physician (PCP) Ask a question using the Send a Message feature Members with a UW Health medical provider can Receive test results online Schedule, cancel and view appointments View and print information about selected health issues, medications, allergies and immunizations Send secure electronic messages to your health care team Access billing information View information for your children. (All features are available for children ages For children ages access is restricted to information about allergies, immunizations, sending messages and scheduling appointments. You cannot review appointments for children ages ) ChooseUnityHealth.com Through Unity s website for State of Wisconsin and Local Government participants you also have access to Healthwise Knowledgebase (A-Z Health Topics) to answer your medical questions Find a Doctor Provider Search function allows you to create customized provider directories Health information such as a Preventive Care Guideline and Unity s asthma and diabetes programs Unity s wellness program, Fitness First & More Unity s Member Guide a comprehensive primer on managed care Links to the websites for Wisconsin Department of Employee Trust Funds (ETF) Navitus Health Solutions Momentum Insurance Plans Unity s Member Confidentiality Notice And much, much, more! UW Health Provider Network The UW Health Provider Network in Dane County includes 4 hospitals 37 primary care clinics Providers in the communities of Black Earth and Cambridge can be found in the Unity Community Provider network. To find out if your practitioner or hospital is a network provider Visit ChooseUnityHealth.com/findadoctor Call Unity Customer Service at (800) Review the provider listings in this directory viii ChooseUnityHealth.com

11 H E A LT H A N D W E L L N E S S Well Wisconsin Well Wisconsin is a wellness program that promotes learning more about your personal wellness and taking control of your health. Every adult on your state health insurance plan can participate in Well Wisconsin, including your spouse, domestic partner and adult children who are 18 years and older. When you complete Unity s online Health Survey through Unity s MyChart and complete a Wellness Assessment at a workplace event, you are eligible to receive a $150 incentive check from Unity.* You can also get your wellness screening at your physician s office. The online Health Survey is a short questionnaire about your health habits. It will highlight healthy habits and suggest areas on which to improve. You can complete the Health Survey at ChooseUnityHealth.com by logging into MyChart and selecting Wellness. The Wellness Assessment will measure your blood pressure, cholesterol level, glucose, and height / weight. You can complete the Wellness Assessment at a screening event held at your employer s location or by completing the 2015 Wellness Assessment Exception form, located on the Well Wisconsin website or within MyChart, with verifiable information from your physician. For more information about Well Wisconsin and to find the schedule for on-site Wellness Assessments visit Fitness First & More Fitness First & More incorporates exercise, nutrition, weight loss and other activities to give you a well-rounded approach to your health and wellness goals whether you want to lose weight, eat better or reduce your stress level. Plus, by participating in Fitness First & More you can receive rewards for taking steps toward leading a healthy lifestyle. How You Can Earn Your Rewards / Reimbursements Through Fitness First & More Fitness First & More offers a maximum $200 reward / reimbursement per calendar year.* Here are the ways you can earn it. Fitness First Fitness First, Health Education, Health Education, Integrative Medicine, Maximum Only Integrative Medicine, Community Supported Agriculture Reimbursement Community Supported Agriculture and Weight Watchers and Weight Watchers Single Coverage $200 or $100 for Fitness First and $100 for all other activities or $100 $200 Family Coverage $200 or $200 or $200 $200 *Please note all health and wellness rewards and reimbursements paid to adult members are considered taxable income to the subscriber and Unity is required to report these to your employer. Health information, including your responses to the Health Survey, is protected by federal privacy law and will not be shared with your employer. ChooseUnityHealth.com ix

12 H E A LT H A N D W E L L N E S S About the Fitness First & More Program As a member of Fitness First & More, you can participate in a variety of different activities, including Fitness First Exercise at a participating health club 60 times in six consecutive months and earn a reward. Health Education classes Take a health education class at any Unity participating hospitals, clinics or other approved vendors and get reimbursed. Integrative medicine Receive a reimbursement for integrative medicine services like acupuncture, Feldenkrais, Healing Touch, massage therapy or Bodywork from UW H ealth Integrative Medicine specialists, Fitness First approved health clubs or Health First vendors. Weight Management Attend Weight Watchers meetings, participate in Weight Watchers online or participate in Diet Free and be reimbursed. Community supported agriculture Purchase a qualifying produce share from a member FairShare Community Supported Agriculture Coalition farm and get reimbursed. Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at (800) and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. Health First Health First provides discounts on products and services that help create positive changes in a member s personal health. Discounts are available on eyeglasses, massage therapy, sports equipment and more! Fitness First for Kids Fitness First for Kids is an exercise reward program for kids between the ages of 5 and 18 who are insured dependents of a Unity subscriber. Kids can earn prizes for being physically active a minimum of 30 minutes a day. To learn more about this program go to ChooseUnityHealth.com and select Health & Wellness, Wellness Rewards and then Fitness First for Kids. Preventive Health Programs Immunization Programs Childhood vaccines prevent many infections that can affect children, adolescents, and adults. Unity has several immunization initiatives in place, including Childhood Immunizations Reminder mailing to parents at 10 months: Varicella (chickenpox) reminder 12 months: Immunization schedule from CDC for birth until 6 years old 19 months: Fill-it-in & Win brochure Fill-it-in & Win Incentive Program Reward program for 2 year olds who have completed CDC recommended vaccines Adolescent Immunizations Reminder immunization schedule from CDC for 7-18 year olds 12 years old (sent in the month of the member s 12th birthday) HPV reminder letter sent to members who have received first or second vaccination, to schedule second or third vaccination x ChooseUnityHealth.com

13 H E A LT H A N D W E L L N E S S Breast Cancer Screening Program A potentially deadly disease like breast cancer is highly curable when caught in the early stages. Unity strives to remind our female members of the importance of preventive screenings. We send reminders to female members who are past due for their screening, as well as a reminder to their primary care physician. In addition, as members turn 40 and 50 years of age we send a letter and educational brochure to help them remember to schedule a mammogram. Cervical Cancer Screening Program Cervical cancer, like breast cancer, is highly curable when caught in the early stages. Because getting a Pap test is so important, we send reminders to all age appropriate women who are past due for this service as well as a reminder to their primary care physician. In addition, as members turn 18, 40 and 50 years of age, we send a letter and educational brochure to help them remember to schedule a Pap test. Preventive Health Care Guideline Unity has adopted a Preventive Health Care Guideline so members can plan routine care visits to keep healthy. The guideline contains preventive service recommendations for infants, children, adolescents, adults and women thinking of becoming pregnant. Smoking Cessation Program Smoking is the single most preventable cause of death and disease in our nation, according to the Centers for Disease Control (CDC). Unity understands how hard it is to quit tobacco and works with our to provide the information and services to help their patients quit. State and Local Government participants are eligible to receive six consecutive 30-day supplies per calendar year of pharmacotherapy (which requires a written prescription from a physician) that can help tobacco users quit. We also provide tobacco cessation resources to help the tobacco user get connected with personnel trained for support in quitting. Health Management Programs For more information about any of the following Health Management programs, call toll-free (866) Asthma Program Unity has developed a unique program to support members who have asthma. Our program concentrates on education, improving selfmanagement skills and encouraging strong partnerships between patients and their. Regular services include annual flu vaccine reminder and informational mailings with tools and tips for managing asthma. Diabetes Program Unity has many initiatives to help members control their diabetes, such as a guideline for living with diabetes, a diabetes self-management magazine, reminders about screenings to prevent complications of diabetes, such as annual dilated eye exam and annual flu vaccine. Depression Health Management Program Unity has developed a program for members with chronic, situational or postpartum depression. Participating members will receive periodic educational mailings. Hypertension Program For members with high blood pressure Unity has developed a hypertension program. If you have other conditions, such as diabetes, high cholesterol or chronic kidney disease, you will be sent periodic mailings about high blood pressure. In addition, your practitioner will receive reminders when lab tests are due. 9 Months & More Unity s 9 Months & More program provides education and guidance to help you through your pregnancy and the delivery of your baby. It is available to all Unity members who are pregnant. The program runs from the time you are identified as being pregnant until two months after you deliver. You will receive information about the stages of your pregnancy, a call from our Quality Care Coordinator each trimester, an optional free health and safety text message program and a postpartum gift upon successful completion of the program. ChooseUnityHealth.com xi

14 H E A LT H A N D W E L L N E S S Patient Safety Patient safety continues to be a growing concern and health care challenge for our country. A part of the solution is for, hospitals, clinics and health plans to continue to improve upon standards of care. These improvements include reducing errors during surgery, decreasing inpatient mistakes, improving accuracy in prescriptions to make them clearer and clarifying treatment plans for patients. Patients, like you, are encouraged to take an active role in staying safe while under medical care. Asking questions and talking openly and honestly with your can help you avoid dangerous mistakes. A checklist to help you prepare for your appointments is available at unityhealth.com/appointmentplanning. Unity has encouraged its participating hospitals, both in urban and rural areas, to complete and submit information to Leapfrog, an organization that gathers and reports information on hospital quality and patient safety efforts. Unity also encourages hospitals to submit survey information to the Wisconsin Hospital Association s (WHA) CheckPoint. CheckPoint gathers and reports information about safety and quality improvement programs from medical clinics and hospitals throughout the state. Results of these initiatives are available by visiting and What You Can Do One of the most important ways to stay safe and healthy is to treat your practitioner as a partner in your health care. Here are some tips to help keep you safe 1. Ask questions and get explanations when you don t understand your health care practitioner. 2. Be open and honest when your practitioner asks you questions. 3. Keep a list of all the medications you are taking. Know the dose and purpose of each medication. 4. Check your prescription when you pick it up from the pharmacy. 5. Know what tests are being done, why they are being done and the risks and anticipated results. 6. Openly discuss all of your treatment options with your practitioner, do not be afraid to ask for a second opinion. 7. Talk to everyone who is providing your care. 8. Bring a family member or friend to your appointment; during a stressful situation, it helps to have another person present. 9. Make sure everyone who handles your care in the hospital checks your identification bracelet for information. 10. Educate yourself about your condition. Patient safety begins with you, the patient. Standards designed by the health care industry and patient safety groups not only hold health care professionals responsible, but should assist you in being a more active and informed member of your health care team. If you are interested in learning more about any of Unity s Health and Wellness programs, requesting additional information is easy. You can Visit ChooseUnityHealth.com and select Health & Wellness. Call Unity Customer Service at (800) xii ChooseUnityHealth.com

15 B E N E F I T S W H A T S C O V E R E D? The Schedule of Benefits is not the contract of insurance. All benefits are paid according to the terms of the Master Contract between Unity Health Plans Insurance Corporation and the Group Insurance Board. Uniform Benefits and this Schedule of Benefits are wholly incorporated in the Master Contract. The Schedule of Benefits describes certain essential dollar or visit limits of your coverage and cer tain rules, if any, you must follow to obtain covered services. In some situations (for example, emergency services received from a non-plan provider), benefits will be determined according to the usual and customary charge. A change to another health plan will result in all benefit maximums restarting at $0 with the exception of the prescription annual out-of-pocket limit. This does not include dental and orthodontia benefits that Health Plans may offer that are not a part of Uniform Benefits. Except as specifically stated for emergency and urgent care (see Sections III., A., 1. and 2. in the It s Your Choice: Reference Guide), you do not have coverage for services from non-plan providers unless you get a prior authorization approved by Unity. Prior Authorization requirements are described in the Health Plan Descriptions section of the It s Your Choice: Decision Guide. MEDICAL BENEFITS FOR STATE PARTICIPANTS The covered benefits that are administered by Unity are subject to the following Policy deductible, coinsurance and medical copayments described below Benefit State Eligible Participants who are not Medicare Prime Participants High Deductible Health Plan for of Wisconsin eligible for nor enrolled in eligible Participants who are Medicare as the primary payor 3 not eligible for nor enrolled in Medicare as the primary payor 3 Annual Medical None None $1,500 per individual plan Deductible $3,000 per family plan Deductible includes prescription drugs and Uniform Dental allowable services and applies to Out-of-Pocket-Limit (OOPL). Annual Medical 90% / 10% except as described 100% except as described below 90% / 10%. Coinsurance applies Coinsurance below. Coinsurance applies to for: durable medical equipment, to OOPL except as described Out-of-Pocket-Limit (OOPL) except cochlear implants and hearing aids. below. as described below. Then, 80% to OOPL. Annual Medical $500 Participant / $1,000 aggregate None except as described below $2,500 per individual plan Out-of-Pocket Limit family limit except as described for: durable medical equipment, $5,000 per family plan (OOPL) below. 1 cochlear implants and hearing aids. except as described below. Then, 80% to OOPL. 1 Routine, preventive 100% 100% 100% services as required by federal law Illness / injury related 90% (10% member cost to OOPL) 100% 90% (10% member cost to OOPL) services Emergency Room $75 does not accumulate to OOPL, $60 After deductible, $75 copayment Copay (Waived if after copay 90%. to OOPL. After deductible and admitted as an (10% member cost to OOPL) copay, 90% (10% member inpatient directly from cost to OOPL) the emergency room or for observation for 24 hours or longer.) Medical Supplies, 80% (20% member cost to OOPL) 2 80% to an annual OOPL 80% (20% member cost to OOPL) 2 Durable Medical of $500 per participant; Equipment and Durable no aggregate family limit Diabetic Equipment (20% member cost to OOPL) 2 and Related Supplies Under no circumstances will you pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,600 single / $13,200 family for federally required essential health benefits. 1 Note that some services will continue to be paid by you past the OOPL, including emergency room and Level 3 prescription drug copayments. 2 Federally required preventive services are covered at 100%. 3 State of Wisconsin Medicare eligible annuitants and their Medicare eligible dependents are limited to participation under the Medicare Prime Uniform Benefits Schedule of Benefits. ChooseUnityHealth.com xiii

16 B E N E F I T S W H A T S C O V E R E D? MEDICAL BENEFITS FOR STATE PARTICIPANTS Benefit State Eligible Participants who are not Medicare Prime Participants High Deductible Health Plan for of Wisconsin eligible for nor enrolled in eligible Participants who are Medicare as the primary payor 3 not eligible for nor enrolled in Medicare as the primary payor 3 Cochlear Implants for 90% hospital charges 100% hospital charges. 90% hospital charges Participants age 18 (10% member cost to OOPL). 80% device, surgery for (10% member cost to OOPL). and older 80% device, surgery for implantation, follow-up sessions 80% device, surgery for implantation, follow-up sessions to train on use (20% member cost implantation, follow-up sessions to train on use (20% member does not apply to OOPL). to train on use (20% member cost does not apply to OOPL). cost to OOPL). Cochlear Implants As required by Wis. Stat. 100% hospital, device, surgery for As required by Wis. Stat. Participants under (16), 90% for hospital implantation and follow-up (16), 90% for hospital age 18 charges, device, surgery for sessions to train on use. charges, device, surgery for implantation and follow-up sessions implantation and follow-up to train on use. (10% member cost sessions to train on use. to OOPL) (10% member cost to OOPL) Hearing Aids for 80% (20% member cost 80% (20% member cost 80% (20% member cost Participants age 18 does not apply to OOPL) does not apply to OOPL) does not apply to OOPL) and older. One aid per Maximum health plan payment Maximum health plan payment Maximum health plan payment ear no more than of $1,000 per hearing aid. of $1,000 per hearing aid. of $1,000 per hearing aid. once every 3 years. Hearing Aids for As required by Wis. Stat. As required by Wis. Stat. As required by Wis. Stat. Participants under (16), 90% (16), 100% (16), 90%. age 18 (10% member cost to OOPL) (10% member cost to OOPL) Temporomandibular 80% (20% member cost to OOPL) 80% (20% member cost to OOPL) 80% (20% member cost to OOPL) Joint Disorders for intraoral splints as Durable for intraoral splints as Durable for intraoral splints as Durable Medical Equipment. Other services Medical Equipment. Other services Medical Equipment. Other services 90% (10% member cost to OOPL). 100%. Maximum health plan 90% (10% member cost to OOPL). Maximum health plan payment of payment of $1,250 for diagnostic Maximum health plan payment $1,250 for diagnostic procedures procedures and nonsurgical of $1,250 for diagnostic procedures and nonsurgical treatment per treatment per participant and nonsurgical treatment per participant per calendar year. per calendar year. participant per calendar year. Dental Implants 90% (10% member cost to OOPL) 100% following accident or injury 90% (10% member cost to OOPL) following accident or injury up to a up to a maximum health plan following accident or injury up to maximum health plan payment payment of $1,000 per tooth. a maximum health plan payment of $1,000 per tooth. of $1,000 per tooth. Prescription Drugs Benefits provided by Navitus Benefits provided by Navitus Benefits provided by Navitus Health Solutions. Health Solutions. Health Solutions. Subject to medical deductible above. After deductible, subject to copays, to $2,500 per individual plan $5,000 per family plan OOPL. Under no circumstances will you pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,600 single / $13,200 family for federally required essential health benefits. 1 Note that some services will continue to be paid by you past the OOPL, including emergency room and Level 3 prescription drug copayments. 2 Federally required preventive services are covered at 100%. 3 State of Wisconsin Medicare eligible annuitants and their Medicare eligible dependents are limited to participation under the Medicare Prime Uniform Benefits Schedule of Benefits. xiv ChooseUnityHealth.com

17 B E N E F I T S W H A T S C O V E R E D? MEDICAL BENEFITS FOR STATE PARTICIPANTS Lifetime Maximum Benefit on all Medical and Pharmacy Benefits None Ambulance Covered as medically necessary for emergency or urgent transfers. Diagnostic Services Limitations Prior Authorization may be required. Outpatient Physical, Speech and Occupational Therapy Maximum Covered up to 50 visits per participant for all therapies combined per calendar year. This limit combines therapy in all settings (for example, home care, etc.). Additional medically necessary visits may be available when prior authorized by Unity, up to a maximum of 50 visits per therapy per participant per calendar year. Cochlear implants Device, surgery for implantation of the device, follow-up sessions to train on use of the device when medically necessary and prior authorized by Unity and hospital charges. The participant s out-of-pocket costs are not applied to the annual out-of-pocket maximum. As required by Wis. Stat (16), cochlear implants and related services for participants under 18 years of age are payable as described in the preceding grid. Hearing aids One hearing aid per ear no more than once every three years payable as described in the preceding grid, up to a maximum payment of $1,000 per hearing aid. The participant s out-of-pocket costs are not applied to the annual out-of-pocket limit. As required by Wis. Stat (16) hearing aids for participants under 18 years of age are payable as described in the preceding grid and the $1,000 limit does not apply. Home Care Benefit Maximum 50 visits per participant per calendar year. 50 additional medically necessary visits per participant per calendar year may be available when authorized by Unity. Hospice Care Benefits Covered when the participant s life expectancy is six months or less, as authorized by Unity. Transplants Limited to transplants listed in the benefits and services section of Uniform Benefits in the It s Your Choice: Reference Guide. Licensed Skilled Nursing Home Maximum 120 days per benefit period payable for skilled care. Mental Health / Alcohol / Drug Abuse Services Annual dollar and day limit maximums for mental health / alcohol / drug abuse services are suspended as required by the Federal Mental Health Parity Act. Vision Services One routine exam per participant per calendar year. Non-routine eye exams are covered as medically necessary. (Contact lens fittings are not part of the routine exam and are not covered.) Oral Surgery Limited to procedures listed in the benefits and services section of Uniform Benefits in the It s Your Choice: Reference Guide. Temporomandibular Disorders as required by Wis. Stat (11) The maximum benefit for diagnostic procedures and non-surgical treatment is $1,250 per participant per calendar year. Intraoral splints are subject to the durable medical equipment coinsurance (that is payable at 80%) and apply to the non-surgical treatment maximum benefit. Dental Services Unity offers the Uniform Dental benefit to State Participants. See page xix. Pharmacy benefits are administered by Navitus Health Solutions, LLC, a pharmacy benefits manager (PBM). Members who have Medicare as their primary insurance have the Navitus Medicare Rx (PDP) plan, which is offered by Navitus Health Solutions and underwritten by Sterling Life Insurance Company, a Federally Qualified Medicare Contracting Prescription Drug Plan. ChooseUnityHealth.com xv

18 B E N E F I T S W H A T S C O V E R E D? MEDICAL BENEFITS FOR LOCAL GOVERNMENT PARTICIPANTS The covered benefits that are administered by Unity are subject to the following Policy deductible, coinsurance and medical copayments described below Benefit: Participating WPE eligible Participants WPE eligible Participants WPE eligible Participants High Deductible Health Wisconsin Public in Program Option in PO 6 who are not in PO 4 including Plan WPE eligible (PO 7) Employers (WPE) {PO} 2 and Medicare eligible for nor enrolled Medicare eligible and Participants who are not eligible and enrolled in in Medicare as the enrolled eligible for nor enrolled PO 6 and PO 7 primary payor 3 in Medicare as the primary payor 3 Annual Medical None None $500 per individual $1,500 per individual plan Deductible applies to $1,000 aggregate per $3,000 per family plan. Out-of-Pocket-Limit family Deductible includes (OOPL). prescription drugs. Annual Medical 100% except as described 90% / 10% except as 100% except as described 90% / 10%. Coinsurance Coinsurance below for: durable medical described below. below for: durable medical applies to OOPL except as equipment, cochlear Coinsurance applies to equipment, cochlear described below. implants and hearing aids. OOPL except as implants and hearing aids. Then, 80% to described below. Then, 80% to OOPL. Out-of-Pocket-Limit (OOPL). Annual Medical None except as described $500 Participant / $1,000 After $500 per individual $2,500 per individual plan Out-of-Pocket Limit below for: durable medical aggregate family limit $1,000 aggregate per $5,000 per family plan (OOPL) equipment, cochlear except as described family deductible, none except as described below. implants and hearing aids. below. 1 except as described below Then, 80% to OOPL. 1 for: durable medical equipment, cochlear implants and hearing aids. Then, 80% to OOPL. 1 Routine, preventive 100% 100% 100% 100% services as required by federal law Illness / injury related 100% 90% (10% member cost 100% 90% (10% member cost services to OOPL) to OOPL) Emergency Room Copay $60 $75 does not accumulate $60 After deductible, $75 (Waived if admitted as to OOPL, after copay 90%. copayment to OOPL. an inpatient directly (10% member cost to After deductible and copay, from the emergency OOPL) 90% (10% member cost room or for observation to OOPL) for 24 hours or longer.) Medical Supplies, 80% to an annual OOPL 80% (20% member cost 80% to an annual OOPL 80% (20% member cost Durable Medical of $500 per participant; to OOPL) 2 of $500 per participant; to OOPL) 2 Equipment and Durable no aggregate family limit no aggregate family limit Diabetic Equipment (20% member cost to (20% member cost to and Related Supplies OOPL) 2 OOPL) 2 Cochlear Implants for 100% hospital charges. 90% hospital charges 100% hospital charges. 90% hospital charges Participants age 18 80% device, surgery for (10% member cost to 80% device, surgery for (10% member cost to and older implantation, follow-up OOPL). 80% device, implantation, follow-up OOPL). 80% device, sessions to train on use surgery for implantation, sessions to train on use surgery for implantation, (20% member cost does follow-up sessions to train (20% member cost does follow-up sessions to train not apply to OOPL). on use (20% member cost not apply to OOPL). on use (20% member does not apply to OOPL). cost to OOPL). Cochlear Implants 100% hospital charges As required by Wis. Stat. 100% hospital, device, As required by Wis. Stat. Participants under hospital, device, surgery (16), 90% for surgery for implantation (16), 90% for age 18 for implantation and hospital charges, device, and follow-up sessions to hospital charges, device, follow-up sessions to surgery for implantation train on use. surgery for implantation train on use. and follow-up sessions and follow-up sessions to to train on use. (10% train on use. (10% member member cost to OOPL) cost to OOPL) xvi ChooseUnityHealth.com

19 B E N E F I T S W H A T S C O V E R E D? MEDICAL BENEFITS FOR LOCAL GOVERNMENT PARTICIPANTS Benefit: Participating WPE eligible Participants WPE eligible Participants WPE eligible Participants High Deductible Health Wisconsin Public in Program Option in PO 6 who are not in PO 4 including Plan WPE eligible (PO 7) Employers (WPE) {PO} 2 and Medicare eligible for nor enrolled Medicare eligible and Participants who are not eligible and enrolled in in Medicare as the enrolled eligible for nor enrolled PO 6 and PO 7 primary payor 3 in Medicare as the primary payor 3 Hearing Aids for 80% (20% member cost 80% (20% member cost 80% (20% member cost 80% (20% member cost Participants age 18 does not apply to OOPL) does not apply to OOPL) does not apply to OOPL) to OOPL). Maximum and older. One aid per Maximum health plan Maximum health plan Maximum health plan health plan payment of ear no more than payment of $1,000 payment of $1,000 payment of $1,000 $1,000 per hearing aid. once every 3 years. per hearing aid. per hearing aid. per hearing aid. Hearing Aids for As required by Wis. Stat. As required by Wis. Stat. As required by Wis. Stat. As required by Wis. Stat. Participants under (16), 100% (16), 90% (16), 100% (16), 90%. age 18 (10% member cost (10% member cost to OOPL) to OOPL) Temporomandibular 80% (20% member cost 80% (20% member cost 80% (20% member cost 80% (20% member cost Joint Disorders to OOPL) for intraoral to OOPL) for intraoral to OOPL) for intraoral to OOPL) for intraoral splints as Durable Medical splints as Durable Medical splints as Durable Medical splints as Durable Medical Equipment. Other services Equipment. Other services Equipment. Other services Equipment. Other services 100%. Maximum health 90% (10% member cost to 100%. Maximum health 90% (10% member cost to plan payment of $1,250 OOPL). Maximum health plan payment of $1,250 OOPL). Maximum health for diagnostic procedures plan payment of $1,250 for for diagnostic procedures plan payment of $1,250 for and nonsurgical treatment diagnostic procedures and and nonsurgical diagnostic procedures and per participant per nonsurgical treatment per treatment per participant nonsurgical treatment per calendar year. participant per calendar per calendar year. participant per calendar year. year. Dental Implants 100% following accident or 90% (10% member cost to 100% following accident or 90% (10% member cost injury up to a maximum OOPL) following accident injury up to a maximum to OOPL) following health plan payment of or injury up to a maximum of $1,000 per tooth. accident or injury up to a $1,000 per tooth. health plan payment of maximum health plan $1,000 per tooth. payment of $1,000 per tooth. Prescription Drugs Benefits provided by Benefits provided by Benefits provided by Benefits provided by Navitus Health Solutions. Navitus Health Solutions. Navitus Health Solutions. Navitus Health Solutions. Subject to medical deductible above. After deductible, subject to copays below, to $2,500 per individual plan $5,000 per family plan OOPL. Under no circumstances will you pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,600 single / $13,200 family for federally required essential health benefits. 1 Note that some services will continue to be paid by you past the OOPL, including emergency room and Level 3 prescription drug copayments. 2 Federally required preventive services are covered at 100%. 3 State of Wisconsin Medicare eligible annuitants and their Medicare eligible dependents are limited to participation under the Medicare Prime Uniform Benefits Schedule of Benefits. ChooseUnityHealth.com xvii

20 B E N E F I T S W H A T S C O V E R E D? MEDICAL BENEFITS FOR LOCAL GOVERNMENT PARTICIPANTS Lifetime Maximum Benefit on all Medical and Pharmacy Benefits None Ambulance Covered as medically necessary for emergency or urgent transfers. Diagnostic Services Limitations Prior Authorization may be required. Outpatient Physical, Speech and Occupational Therapy Maximum Covered up to 50 visits per participant for all therapies combined per calendar year. This limit combines therapy in all settings (for example, home care, etc.). Additional medically necessary visits may be available when prior authorized by Unity, up to a maximum of 50 visits per therapy per participant per calendar year. Cochlear implants Device, surgery for implantation of the device, follow-up sessions to train on use of the device when medically necessary and prior authorized by Unity and hospital charges. The participant s out-of-pocket costs are not applied to the annual out-of-pocket maximum. As required by Wis. Stat (16), cochlear implants and related services for participants under 18 years of age are payable as described in the preceding grid. Hearing aids One hearing aid per ear no more than once every three years payable as described in the preceding grid, up to a maximum payment of $1,000 per hearing aid. The participant s out-of-pocket costs are not applied to the annual out-of-pocket limit. As required by Wis. Stat (16) hearing aids for participants under 18 years of age are payable as described in the preceding grid and the $1,000 limit does not apply. Home Care Benefit Maximum 50 visits per participant per calendar year. 50 additional medically necessary visits per participant per calendar year may be available when authorized by Unity. Hospice Care Benefits Covered when the participant s life expectancy is six months or less, as authorized by Unity. Transplants Limited to transplants listed in the benefits and services section of Uniform Benefits in the It s Your Choice: Reference Guide. Licensed Skilled Nursing Home Maximum 120 days per benefit period payable for skilled care. Mental Health / Alcohol / Drug Abuse Services Annual dollar and day limit maximums for mental health / alcohol / drug abuse services are suspended as required by the Federal Mental Health Parity Act. Vision Services One routine exam per participant per calendar year. Non-routine eye exams are covered as medically necessary. (Contact lens fittings are not part of the routine exam and are not covered.) Oral Surgery Limited to procedures listed in the benefits and services section of Uniform Benefits in the It s Your Choice: Reference Guide. Temporomandibular Disorders as required by Wis. Stat (11) The maximum benefit for diagnostic procedures and non-surgical treatment is $1,250 per participant per calendar year. Intraoral splints are subject to the durable medical equipment coinsurance (that is payable at 80%) and apply to the non-surgical treatment maximum benefit. Dental Services No dental benefits are provided to Local Government Participants. Pharmacy benefits are administered by Navitus Health Solutions, LLC, a pharmacy benefits manager (PBM). Members who have Medicare as their primary insurance have the Navitus Medicare Rx (PDP) plan, which is offered by Navitus Health Solutions and underwritten by Sterling Life Insurance Company, a Federally Qualified Medicare Contracting Prescription Drug Plan. xviii ChooseUnityHealth.com