Member Guide. Welcome. to Unity Health Insurance

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1 Member Guide Welcome to Unity Health Insurance

2 K E E P T H I S G U I D E F O R F U T U R E R E F E R E N C E Know Your Health Plan The Member Guide is for informational purposes only. It is only a partial, general description of Unity features and benefits. It is not a contract nor any part of one. The complete terms of your health plan are in your Certificate of Coverage. If there are any differences between this Member Guide and your Certificate of Coverage, your Certificate of Coverage is the controlling document. Before seeking any health care under your Unity health plan, please review the following resources very carefully. Together, they will provide the information you need to know to make the most of your health plan benefits: Member Guide Unity Network Provider Directory* Medicare Select Provider Directory* (Medicare Select members only) State of Wisconsin UW Health Provider Directory* State of Wisconsin Community Network Provider Directory* BadgerCare Plus Provider Directory* Certificate of Coverage Schedule of Benefits or Summary of Benefits and Coverage It s Your Choice: Decision and Reference Guides (State of Wisconsin and Local Government Participants only) * Providers are independent contractors and not employees of Unity Health Plans Insurance Corporation. Most of the information in this Member Guide pertains to all Unity members; however, My Choice, POS, Choice Plus, and PPO members will also find information that applies just to them on pages Unity Customer Service If you have any questions about your benefits, send a message to Unity Customer Service through Ask an Expert within MyChart at or call Monday through Friday (7 a.m. to 5 p.m. Central Time) (toll-free) (local) (fax) (hearing impaired) Pharmacy Services: If you are unable to contact Unity during normal business hours, you may call and leave a voic 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 during normal business hours. Unity customer service representatives will gladly assist you in getting answers to your health care coverage questions. If you need language assistance, please see the contact information below. Other Sources of Information Read our quarterly newsletter, UnityNews, for updates to this guide. You can find them at by clicking Members and then Newsletters under Quick Links Visit for information on the following topics: Understanding Your Benefits Plan information Find A Doctor Interactive look-up of Unity providers Health & Wellness Flu Information Preventive Health Managing Your Health Diabetes Tobacco Cessation Asthma Pregnancy and Childbirth Hypertension Behavioral Health Health Appointment Planning Fitness First & More Interactive Tools Health Risk Assessment (HRA) Healthy Recipes Using Your Pharmacy Benefits Understanding Your Pharmacy Benefits Choosing a Pharmacy UW Health Pharmacies Contact Information Important Questions to Ask MyChart View benefit information Check claims status Secure contact with a Unity customer service representative Receive electronic Explanation of Benefits Take a Health Risk Assessment Review Prior Authorizations Plus, if you receive care from UW Health you can view portions of your UW Health medical information 1

3 Contents In recognition of our ability to achieve our service goals, Unity has been awarded a fourth Excellent Accreditation from the National Committee for Quality Assurance (NCQA). See page 34 for more information. Commercial HMO and POS 2 Welcome to Unity Health Insurance 4 Understanding the Concept of Managed Care What is Managed Care? Why Choose Managed Care? 5 Enrollment & Eligibility Information New Member Enrollment Information Your Subscriber/Member Identification Card Changes to Your Enrollment Information Dependent Information Other Insurance Coverage Continuation and Conversion Plans 10 Accessing Primary Care How to Obtain Information about Practitioners and Providers Why Choose a Primary Care Physician (PCP)? How to Choose Your PCP Tips for Selecting a PCP MyChart How to Change Your PCP Making an Appointment for Routine Care After-Hours Clinic Care Accessing Care Away From Home Well-Child Care 13 Accessing Specialty Care Specialty Care Services Procedures and Equipment Requiring Prior Authorization Dental/Oral Surgery, Optometric, Chiropractic, and OB/GYN Behavioral (Mental Health/AODA) Health Care Services Maternity Care Hospital Care 16 Accessing Urgent & Emergency Care Services Urgent Care Services When You Need Urgent Care Emergency Care Services What To Do In Case of An Emergency Follow-up Care for Urgent and Emergency Care Services 18 Pharmacy Benefits & Services Prescription Drug Benefit Prescription Drug Formulary How is the Formulary Developed? Medication Prior Authorization Generic Drugs Why Choose a Generic? Unity s Generic Substitution Policy Vacation Supply of Drugs Step Therapy Program Emergency Drug Supply New Member Drug Supply RX 90 Extended Supply Program Specialty Pharmaceuticals Program Half-Tab Program RX Outcomes Refill Policies 22 Medical & Complex Case Management Guidelines for Care Complex Case Management 23 Claims & Payment Information Claims Submission Out-of-Pocket Expenses 25 Information for POS Members How POS Plans Work My Choice Member Information POS Member Information Choice Plus Member Information 29 Information for PPO Members How the PPO Plan Works PPO Member Information 30 Member Rights & Responsibilities Special Needs Complaints and Grievance Resolution Member Rights Member Responsibilities Confidentiality and Privacy Policies Women s Health and Cancer Rights Act 34 Quality Improvement Programs NCQA Accreditation HEDIS Reporting Member Satisfaction Evaluation of New Medical Technology Ensuring Quality Practitioners and Providers 36 Glossary of Commonly Used Managed Care Terms 1

4 W E L C O M E T O U N I T Y H E A L T H I N S U R A N C E to Unity Health Insurance Welcome to Unity Health Insurance ( Unity ). Our goal is to keep our members healthy while managing the cost of care. Unity provides programs and services to meet your health care needs. We work to provide you with attentive service and quality care through our large network of participating providers. Unity strives to offer convenient access to health care within our service area. Mission Unity is a growing, financially strong organization that provides managed health insurance products and services. We promote quality health care for our members and deliver value to our customers and strategic partners. The cornerstones of this mission are: Choice A variety of benefit options and a broad choice of providers. Access Health care delivered by local, community-based providers with access to state-of-the-art specialty and tertiary care. Value Competitive pricing, administrative efficiency and customer satisfaction. Quality Measurement and improvement of health care processes and outcomes. Vision Unity will be the preferred managed health insurance partner of employers, members, providers and the communities we serve. Customer Service Philosophy Providing excellent customer service is a company-wide goal at Unity. Every employee is dedicated to ensuring members have a high level of satisfaction with their Unity health plan. Unity employees follow a philosophy that helps us provide the high level of service our members deserve. Our Philosophy 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 2

5 W E L C O M E T O U N I T Y H E A L T H I N S U R A N C E Health Plan Options Health plan refers to the type of coverage you have. Unity offers a number of health plan options: Health Management Organization (HMO) Plan Members who have this plan agree to obtain all non-emergent health care services through a defined network of doctors, hospitals and other medical professionals. POS Plan This plan allows members flexibility in seeking medical care, with options to stay in plan or go out-of-plan to seek health care services. Refer to page 27. PPO Plan The PPO Plan allows members to access care from providers throughout the United States. See page 29 for more information. HSA-Qualified High Deductible Health Plans (HDHP) High Deductible Health Plans are plans with federally defined deductible limits. By having a HDHP, the subscriber is eligible to open a Health Savings Account (HSA), a tax savings vehicle. Individual Health Insurance Plan Unity offers health plans for individuals and families. Members with coverage under a Unity individual product should contact Unity Customer Service when this Member Guide refers to Your Employer s Benefit Administrator. Medicare Select Plan Unity offers supplemental health insurance plans for individuals who are currently enrolled in Medicare Part A and B. Please visit for more information about these plan types. 3

6 U N D E R S T A N D I N G T H E C O N C E P T O F M A N A G E D C A R E Understanding the Concept of Managed Care More information about Unity s health programs can be found at. What is Managed Care? The philosophy of managed care is to provide members with preventive services in order to keep them healthy. Healthy members are less likely to need more expensive medical care. Managed Care Organizations (MCOs) attempt to reduce costs by creating provider networks through which all members receive their health care. Unity works with its network of providers to ensure members receive timely and appropriate medical care and that unnecessary or untested services are not provided. Unity and its participating providers develop programs to improve member use of preventive health care services. By focusing on prevention of illness and management of chronic disease, members have more control over their health. Why Choose Managed Care? Managed care empowers members to proactively seek preventive health care services. It better suits today s active lifestyle because of these features: Convenient Access Unity s service area covers southwestern and south central Wisconsin. Participating provider clinics are situated to provide you and your family with accessible health care services. Streamlined Administration You are virtually free of hassles and follow-up paperwork when you use an in-network provider and follow any applicable referral requirements. In most cases, your practitioner will submit claims directly to Unity. Coordination of Care Your relationship with your Primary Care Physician (PCP) is important. Your PCP works with you to coordinate all of your health care services. Care Management Doctors and nurses in Unity s care management program, working with your PCP, review treatment plans and requests to coordinate your care. Health Education and Wellness Unity has partnerships with a variety of community providers that offer health education classes and services that can improve your health and well-being. Preventive Health Care Unity has adopted a Preventive Health Care Guideline to help you and your family plan routine visits to your PCPs. This guideline promotes preventive health care services such as age appropriate physical exams, well-child care, cervical cancer screenings, mammograms, and many other services to keep you and your family healthy. 4

7 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N Enrollment & Eligibility Information New Member Enrollment Information You will receive your new member materials when you enroll. This includes useful information regarding Unity and your new health plan. Unity encourages you to read your enrollment information thoroughly. Please note that in the future you will receive a new ID card and Schedule of Benefits or Summary of Benefits and Coverage at your group s renewal date only if there are changes to your health insurance benefits. If you misplace an item or have questions, log into MyChart or contact Unity Customer Service. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information. Your Subscriber/Member Identification Card (ID Card) Your new member information kit includes two ID cards. These cards identify you (the subscriber) and your covered dependents, your group number, a PCP for each family member (if applicable), your provider network and health plan (see page 3). For additional or replacement ID cards, visit and login to MyChart or call Your new ID cards will be sent to you within 5-7 business days. Unity knows that privacy is very important to you which is why your member ID number is a randomly assigned number. 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 or pharmacy when you seek services. Always have your member ID card with you each time you access services from an in-network health care provider or when contacting Unity Customer Service. 5

8 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N The front of your Unity member ID card includes the following information: Your Network Use this to search for providers in Find A Doctor: Individual Health Insurance member ID cards will indicate Personal Options in the Your Network section of the HMO ID card. Use Unity Network to search for providers. State of Wisconsin health insurance program member ID cards will indicate State/Local and then either UW Health or Community based on the network chosen in the Your Network section of the HMO ID card. Medicare Select member ID cards will indicate Medicare Select in the Your Network section of the HMO ID card. Use Unity Network to search for providers. HMO Deductible member ID cards will indicate the single/family deductible amounts in the Your Network section of the HMO ID card. Use Unity Network to search for providers. PPO member ID cards will indicate HealthEOS or PHCS in the Your Network section. Subscriber Name Full name of the subscriber. Subscriber No. The subscriber number is a unique number assigned to each individual subscriber. Group No. The group number identifies the subscriber s employer group and is usually the same for all Unity members and their dependents within that employer group. Benefit This lists a summary or code for the benefit coverage for the group, including any office visit and prescription drug copayment amounts. The subscriber s PCP name may also be printed below the benefit information. Member Name Each member/ dependent is listed under member name, along with each individual member s PCP name, clinic name, and telephone number. Person Code Each member/ dependent is identified by a person code. This person code is the last two digits of the member s identification number. The subscriber will always have person code 00. Please include the appropriate person code whenever you contact Unity regarding a specific member. PCP The clinic and Primary Care Physician (PCP) for each member is listed, along with the clinic phone number. Each member shown on a card can have a different PCP. Note: There may be certain circumstances when this information may not be listed. The back of your Unity member ID card also contains important information be sure to read it before using your card. Remember the following: Verify the information on your ID card right away. Notify Unity Customer Service if any changes are needed. It is necessary to present your ID card every time you receive medical care. This includes services at a pharmacy. Please note: State of Wisconsin and Local Government participants should use their Navitus Health Solutions LLC ID card at the pharmacy. BadgerCare Plus members should use their Forward or ForwardHealth card. Notify Unity Customer Service immediately if you lose your ID card or if it is stolen. Do not allow anyone else to use your ID card unless they are insured under your Unity policy. HMO Front Back 6

9 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N My Choice My Choice Your Network: Subscriber Name Subscriber No. Group No. Benefit Tier 1 Tier 2 IA Tier Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use non-participating providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations and Pre-certifications. Member Name Front Person Code Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) Back PRE-CERTIFICATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a non-participating provider. For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation POS Point of Service (POS) Your Network: 840 Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use out-of-network providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations. PRIOR-AUTHORIZATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a out-of-network provider. Front Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation Back 7

10 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N PPO Your Network: Subscriber Name Subscriber # Group # Your Network: Subscriber Name Subscriber # Group # Member Name Person Code Member Name Person Code Members: You must notify Unity s Medical Management ( ) within 48 hours of inpatient hospitalizations that were emergent/urgent. Benefit Information is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. Prior Authorization: You must contact Unity s Medical management for Prior Authorization at least 48 hours before all elective (non-emergent) hospital admissions, skilled nursing facility admissions and inpatient rehabilitation. Prior Authorization Members: is also required You must for transplants, notify Unity s Medical Management genetic testing, home care services, ( ) home IV therapy, within hospice 48 hours care, of inpatient hospitalizations that and purchase of durable medical were equipment emergent/urgent. (DME) in excess of $500 in total. Some specialty injectible Benefit medications Information administered is available by a within MyChart at. professional require Prior Authorization. Simply request Log into an MyChart account or at call unitymychart.com. An activation code Customer Service to determine if will a Prior be mailed Authorization to your home is needed. within 10 days. Once you receive your You are responsible for this notification activation when code, using follow any the provider. instructions to activate your account. Prior Authorization: You must contact Unity s Medical Management for For Provider Network Information: Prior Authorization at least 48 hours before all elective (non-emergent) For care outside of Wisconsin, call hospital PHCS admissions, at (866) skilled nursing facility admissions and inpatient For care in Wisconsin, call MultiPlan rehabilitation. at (888) Prior Authorization is also required for transplants, You may also use Find a Doctor at genetic testing, home care services, home IV therapy, hospice care, and purchase of durable medical equipment (DME) in excess of $500 Customer Service Send Claims to: in total. Some specialty injectible medications administered by a (800) HealthEOS by MultiPlan professional require Prior Authorization. Log into MyChart or call TDD (608) PO BOX 6090 Customer Service to determine if a Prior Authorization is needed. Fax (608) De Pere, WI You are responsible for this notification when using any provider. Fax EDI Payor # (Emdeon): For members with Unity drug coverage, For For Provider Provider pharmacies Network Network may Information: Information: use: BIN# PCN / RX Group# For For care care in Wisconsin, in Wisconsin, call call HealthEOS HealthEOS at (800) at (800) hour pharmacy: (800) For For care care outside outside of Wisconsin, of Wisconsin, call call MultiPlan MultiPlan at (888) at (888) You You may may also also use use Find Find a Doctor a Doctor at at Customer Customer Service Service Send Send Claims Claims to: to: (800) (800) HealthEOS HealthEOS by by MultiPlan MultiPlan TDD TDD (608) (608) PO PO BOX BOX This card is for identification Fax purposes only Fax (608) (608) De De Pere, Pere, WI WI and does not constitute proof of eligibility Fax Fax (262) (262) Unity Health Plans Insurance Corporation EDI EDI Payor Payor # (Emdeon): # (Emdeon): For For members members with with Unity Unity drug drug coverage, coverage, pharmacies pharmacies may may use: use: BIN# BIN# PCN PCN / RX / RX Group# Group# hour 24-hour pharmacy: pharmacy: (800) (800) HealthEOS by MultiPlan T PO BOX 6090 F De Pere, WI u Fax (262) This This card card is for is for identification identification purposes purposes only only and and does does not not constitute constitute proof proof of eligibility of eligibility Unity Unity Health Health Plans Plans Insurance Insurance Corporation Corporation Front Back Choice Plus Choice Plus Your Network: Subscriber Name Subscriber No. Group No. Benefit Level I Level II Level III 840 Carolina Street Sauk City, WI BENEFIT INFORMATION is available within MyChart at. Simply request an account at unitymychart.com. An activation code will be mailed to your home within 10 days. Once you receive your activation code, follow the instructions to activate your account. URGENT AND EMERGENCY CARE: If you have a serious medical problem where care clearly cannot be delayed, call 911 or obtain care from the nearest medical site. If you are unsure of the urgency of the situation, call your primary care clinic for instructions. If you are admitted to the hospital from the emergency room, you or the hospital staff must notify Customer Service within 3 business days. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hours care. If you use non-participating providers you may incur additional costs and you will be responsible for obtaining Prior Authorizations and Pre-certifications. Member Name Front Person Code PRE-CERTIFICATION: Your participating doctor, hospital staff or provider must call Unity at (800) at least 3 days prior to any non-emergency hospitalization or within 3 business days following an emergency admission. You are responsible for this notification when using a non-participating provider. Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO BOX 610 Sauk City, WI Fax (608) Back For members with Unity drug coverage, pharmacies may use: BIN# PCN# / Rx Group# Unity 24-hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation 8

11 E N R O L L M E N T & E L I G I B I L I T Y I N F O R M A T I O N Changes to Your Enrollment Information You must contact your employer s Benefits Administrator/Human Resources Manager if your enrollment status changes. Notify them of the following changes as soon as possible: Name, address and/or phone number change It is very important you also let Unity know about these changes as quickly as possible. You may do so by logging into MyChart or calling If you update this information at your UW Health clinic, you don t need to contact Unity because it will automatically update in our system. Choosing or changing your PCP See Accessing Primary Care, page 10. Your marriage As the policy subscriber, you must add your spouse to your policy within 31 days following the date of your marriage if you want your spouse insured. Adding a spouse may change your monthly premium. You may be able to add your spouse by logging into MyChart. If not, contact your employer s Benefits Administrator to obtain an enrollment application. If you do not add your spouse within 31 days of marriage, your spouse will be subject to a waiting period. New baby Enroll your newborn under your policy within 31 days following the child s date of birth. Adding a newborn may change your monthly premium. You may be able to add your dependent by logging into MyChart. If not, contact your employer s Benefits Administrator to obtain an enrollment application. Note: A newborn of a dependent (grandchild) may be added only if the dependent parent is under the age of 18. Coverage for the grandchild ends the day the parent turns 18 years of age. Divorce Notify your employer s Benefits Administrator when your divorce is final. You must fill out the necessary paperwork to have your former spouse/stepchildren removed from your policy. Your former spouse/stepchildren may be eligible to continue coverage for a period of time. This is possible through a continuation plan through your employer. You may be able to remove them from your policy by logging into MyChart. If not contact your employer s Benefits Administrator to make these changes. Death of a member Contact your employer s Benefits Administrator to complete the necessary forms. Termination of employment You may be eligible to continue your coverage through your employer group when you leave your job. Contact your former employer s Benefits Administrator for continuation information. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information about enrollment changes. Dependent Information Adopted children, children placed for adoption, stepchildren Legally adopted children, children placed for adoption, or stepchildren who live with you may be eligible for coverage. Contact your employer s Benefits Administrator for details. Adult children Your adult child is eligible for coverage under your plan until age 26. Contact Unity Customer Service or your employer s Benefits Administrator for further details. Disabled dependents Mentally or physically disabled dependents may be eligible to continue coverage under your policy. Contact your employer s Benefits Administrator or Unity Customer Service for further details. Other Insurance Coverage You must inform Unity if or when you have other health insurance coverage. This information ensures your claims will be submitted and processed correctly. Unity coordinates benefits with your other insurance plan. Always give copies of your health insurance identification cards to the providers you see for health care services. If you have any questions regarding the coordination of benefits, contact Unity Customer Service. To inform us of other coverage, please complete the Other Insurance Questionnaire at by clicking Members and then Other Insurance Questionnaire under Quick Links. Continuation and Conversion Plans If you leave your job, are widowed, experience a divorce or separation, or your dependent child is no longer eligible for coverage through your employer, then you, your spouse or your child may be eligible for continuation benefits. Please talk with your employer about continuation. When you are no longer eligible for your employer s coverage, or when your continuation coverage runs out, you may be able to convert to Unity s conversion product or apply for an individual plan. 9

12 A C C E S S I N G P R I M A R Y C A R E Accessing Primary Care Unity s web site,, has a Find A Doctor feature that allows you to search for providers by their name, city, specialty type or facility. How to Obtain Information About Practitioners and Providers Unity s provider directories list participating PCPs, specialists, chiropractors, pharmacies, hospitals and urgent care facilities by city. Unity Customer Service can assist you in locating a PCP/clinic in your area. Your PCP clinic can assist you with specific questions regarding the board certification status, residency and educational background of a particular provider. Note: PPO members, please visit for more information about the PPO network. Why Choose a Primary Care Physician (PCP)? All Unity members must select or be assigned a participating PCP. A PCP is a physician who manages your health care and 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 care providers. Note: My Choice members can choose any non-contracted PCP. PPO members do not need to select a PCP. To effectively manage care and help you obtain an optimal level of health, it s beneficial for you to have a close relationship with your PCP. There is also an established working relationship between your physician and Unity. 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/aoda) practitioners Monitor and coordinate your care if you have a medical condition such as asthma or diabetes Recommend you seek regular preventive health services, such as immunizations, age appropriate physicals and screenings Refer you to participating specialists as needed There are many advantages to having a PCP: The most consistent care is received when one physician has a total history of your health care and can coordinate your care Referrals will be made when needed You will not have to worry about hospital pre-authorization or filing claim forms Out-of-pocket costs can usually be minimized 10

13 A C C E S S I N G P R I M A R Y C A R E How to Choose Your PCP All Unity members must select or be assigned a PCP. Each of your family members has the right to select his/her own participating PCP. The PCP(s) you select for you and your family members may be a: Family Practice Physician (FP) Family Practice with Obstetrics (FP/OB) General Practice Physician (GP) Geriatric Physician (Ger) Internal Medicine Physician (IM) Pediatrician (Peds) OB/GYN Physician (OB/GYN) It is very important you read the introductory section of your provider directory or the help information within Find A Doctor prior to selecting a PCP or PCP clinic. For provider updates, visit Find A Doctor at or contact Unity Customer Service. You should verify the PCP you select is accepting new patients. You can call the clinic directly, visit Find A Doctor at or contact Unity Customer Service to obtain this information. UW Health Welcome Center If you are looking for a PCP at a UW Health clinic and need help selecting one, contact the UW Health Welcome Center at Monday through Friday from 8 a.m. to 5 p.m. You can also send an to In addition to helping you select a PCP, the UW Health Welcome Center will: 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 an appointment at the Welcome Center clinic, if needed Assist you with connecting to community resources if needed Note: My Choice members please see page 25. PPO members please see page 29. Tips for Selecting a PCP It is important to take time to select PCPs for your family. PCPs are trained to serve as a person s primary doctor for the long term. Look for a PCP who: Is highly recommended by your friends, family or co-workers Has the training and background that meet your needs Takes steps to help you prevent illness for example, talks to you about quitting 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 MyChart If you have a UW Health primary care physician, sign up for MyChart to view your health information, schedule appointments and communicate with your primary care team. For more information and to sign up, visit unitymychart.com. How to Change Your PCP You can change your PCP by logging into MyChart or calling If you receive care from UW Health, you can also change your PCP at your clinic. The change will be effective on that day unless you request a future date. Note: If you do not notify Unity Customer Service before visiting a new PCP clinic, you may have to pay for the services that you or a family member received. Making an Appointment for Routine Care Contact your PCP clinic when you need non-emergency services or if you have a UW Health PCP you can schedule an appointment through MyChart. It is important each member of your family works with his/her chosen PCP to receive recommended preventive health care, routine screenings and immunizations. When calling your PCP or PCP clinic, keep in mind you may be able to see a Nurse Practitioner (NP) or a Physician s Assistant (PA) instead of waiting for an appointment with your PCP. NPs and PAs are licensed, highly-qualified professional health care providers who work in partnership with physicians. They are available to assist you with physical exams, urgent or problem visits, and follow-up of ongoing health care. Always show your member ID card to the office staff when you arrive at your appointment. After-Hours Clinic Care If you need medical attention after your primary care clinic s normal business hours, call your primary care clinic. Follow the instructions provided by the clinic s messaging system (even when you are outside the service area). In a medical emergency, go to the nearest emergency room. Refer to page 16 for more information on urgent/emergent care. 11

14 A C C E S S I N G P R I M A R Y C A R E Accessing Care Away from Home (Out-of-Area Care) It is important you understand how to obtain health care when you are away from home. We have separated it into two categories: emergency and urgent care, and routine specialty care. The information on pages 16 and 17 will help you understand the process for obtaining emergency and urgent care. Please follow this process whenever you feel you are in need of emergency or urgent care, whether you are near your home, away at school, or on vacation. Routine, follow-up and specialty care should always be obtained when you arrive home. Listed below are some common situations and what you need to know to correctly obtain care: Specialty care as follow-up after an emergency or urgent care admission: All care received as follow-up to an emergency or urgent care admission must be provided by or arranged by your PCP or participating specialist. See page 17 for more information. Vacation: When on vacation you may need to access emergency or urgent care. You should follow the steps on pages 16 and 17. Follow-up appointments after emergency or urgent care and other routine/preventive care must be obtained from your PCP or from a participating specialist. Students away at school: If your child is a covered dependent living away from home while attending school, that child can obtain emergency or urgent care, as needed, where his/her school is located. HMO subscribers who have dependents that are full-time students over age 18 attending post secondary school outside Unity s service area can receive coverage for non-emergency and non-urgent care that is medically necessary and prior authorized. All care must be prior authorized through Unity Medical Management at before care is received in order for services to be covered. For covered services, Unity will pay non-participating providers located outside Unity s service area 50% of usual, customary and reasonable charges, as determined by Unity, up to the maximum benefits stated on the Schedule of Benefits. Note: The enhanced HMO benefit for full-time students is not available to State of Wisconsin and Local Government Participants. Winter away from home: Many Unity members spend several of the winter months in a warmer climate. While you can obtain emergency or urgent care at your winter destination as needed, you must obtain routine and follow-up care from your PCP or a participating specialist. If you are planning extensive travel, you should speak with your PCP to discuss how to obtain necessary medical care while you are away. It is important you are aware of the specialists and facilities that are participating for you and each member of your family so you can correctly obtain routine and follow-up care as necessary. Please refer to Find A Doctor or the front of your provider directory for more information about the providers available to you. Out-ofarea care is limited to usual, customary and reasonable charges. My Choice, POS, Choice Plus and PPO members should see pages to understand how their benefits will pay if they obtain routine, specialty or follow-up care from a provider that is not participating under their Unity plan. Well-Child Care Your child s health and well-being are assessed during well-child exams. In addition, this is a time to discuss disease prevention and health care promotion with your child s PCP. This includes age appropriate immunizations that are a good way to prevent many diseases which can affect young children and adolescents. Children should receive vaccinations according to the recommended schedule in the Preventive Health Care Guideline. The Preventive Health Care Guideline is reviewed at least every two years and can be viewed and printed at. You can also request a paper copy by calling

15 A C C E S S I N G S P E C I A L T Y C A R E Accessing Specialty Care Specialty Care Services Your PCP is responsible for providing primary care services and for coordinating your health care needs. In most cases, your PCP can provide the medical care you need; however, when necessary, your PCP can also refer you to a participating Unity specialist for specialty care. Unity does not require HMO members to receive a referral from their PCP prior to accessing specialty care, however it is beneficial to have a strong working relationship with the PCP. Out-of-plan referral requests will be reviewed only for services that are not available from our participating providers. Services are subject to medical necessity, all benefit maximums, policy limitations and exclusions, and eligibility requirements and are covered up to usual, customary and reasonable charges. For a description of your covered benefits, please refer to your Schedule of Benefits or Summary of Benefits and Coverage and your Certificate of Coverage. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice: Decision and Reference Guides for more information. For hospital services, your admitting physician must contact Unity for approval and prior authorization. For elective or planned hospital services, you must use a participating hospital. Contact Unity Customer Service to see if your plan requires Prior Authorization. (If you are a My Choice, POS, Choice Plus, or PPO member, see pages ) Procedures and Equipment Requiring Prior Authorization Some medical procedures and equipment require Prior Authorization. This means your physician must obtain approval from Unity before you can obtain these services. On the next page you will find a list of common procedures requiring Prior Authorization. For a complete list of services that require Prior Authorization, please visit and click Members and then Prior Authorization under Quick Links or contact Unity Customer Service. Note: My Choice, POS and Choice Plus members are responsible for obtaining Prior Authorization for services received from a Tier 2 or out-of-network provider. PPO members, please visit to see what services require Prior Authorization under your plan. Please note: The procedures and equipment requiring prior authorization may not be covered benefits under your health insurance plan. 13

16 A C C E S S I N G S P E C I A L T Y C A R E Members will need Prior Authorization (PA) for the following: Abortions AODA Services Bone Anchored Hearing Aid (BAHA) Behavioral Health Services Biodex Blepharoplasty (Eyes) Cochlear Implants Cosmetic Surgery Treatments Durable Medical Equipment Elective Hospital Admissions Electrolysis Enhanced External Counter Pulsation (EECP) Experimental/Investigational Procedures Genetic Testing Genioplasty (Chin) Home Health Care Hospice Hyperbaric Treatments IDET Procedure Light Therapy [i.e. Levulan Photodynamic or Pulsed Dye Treatments or Actinotherapy (ultraviolet light therapy for acne only; does not require PA for actinic keratoses)] Liposuction Mole Mapping Multifetal Pregnancy Reduction Neuropsych testing (for Behavioral Health only) Osteotomy/Ostoplasty (Mandibular) Panniculectomy (Lipectomy) Penile Implant Prolotherapy Reduction Mammoplasty Revision of Prosthetic Vaginal Graft Rhytidectomy (facelift) Rhinoplasty (nose)/septorhinoplasty Sclerotherapy (Radiofreq ablation, vein stripping, ligation) Skilled Nursing Home Care Treatment of Learning/ Developmental Disabilities TMJ Surgical Treatment Transplants Uvulopalatopharyngoplasty/ Somnoplasty/Uvulectomy LAUP - Laser assisted uvulopalatopharyngoplasty/somnoplasty Warm Water Therapy X Stop Interspinous Implant Pharmacy Prior Authorization is required for some clinic-administered injectable medications. Visit and click Members and then Prior Authorization under Quick Links for the list. Dental/Oral Surgery, Optometric, Chiropractic, and OB/GYN Review your Schedule of Benefits for specific coverage information for these services or contact Unity Customer Service. If you have coverage, simply contact a participating provider to schedule an appointment. Although referrals are not necessary for these services, all benefits are subject to review for medical necessity and to plan limitations and maximums and certain provider limitations. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Behavioral (Mental Health/AODA) Health Care Services Unity members can seek services with a participating mental health or alcohol & other drug abuse (AODA) practitioner without a referral from their PCP, although there are certain practitioner limitations for mental health or AODA services. Unity s network includes psychiatrists, psychologists, social workers, and specialty facilities to meet your behavioral health care needs. Unity members in need of behavioral (mental health care/aoda) health care services can call one number for assistance in getting an appointment with a behavioral health practitioner: UW Behavioral Health at (Behavioral health for all members. AODA for members with a PCP outside of Dane County including Black Earth and Cambridge.) or Gateway Recovery at for AODA (For members with a PCP in Dane County only except Black Earth and Cambridge). These phone numbers connect you with staff who will determine the correct type of behavioral health practitioner who can best meet your needs, and will assist you in getting an appointment in a timely manner. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. 14

17 A C C E S S I N G S P E C I A L T Y C A R E At your first appointment, your mental health or AODA practitioner will evaluate your needs and decide what treatment is necessary. The practitioner will also develop a treatment plan. Your practitioner will get the appropriate authorizations for the recommended treatment. Your Unity plan may have limitations on the amount of coverage available for mental health and AODA services. Review your Schedule of Benefits or Summary of Benefits and Coverage and Certificate of Coverage for a complete list of your benefits. It is important that you keep track of the benefits you have used. Once you reach the benefit maximum, additional benefits are not available until the next benefit year begins. Note: Benefit year differs for each employer group. Confirm the benefit year for your plan by contacting your employer s Benefits Administrator or Unity Customer Service. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Maternity Care Good prenatal care is important for you and your baby. Services for prenatal care, delivery and postpartum care are provided while you are a Unity member according to the terms of your policy. PCPs provide a full range of care, including prenatal and postpartum care. Your PCP can confirm your pregnancy and will advise you on the prenatal and postpartum care you need. You may also see a participating OB/GYN specialist, but an authorization may be required for OB/GYN services in specific circumstances. Members covered under a Unity individual insurance plan must review their Certificate of Coverage and Schedule of Benefits or Summary of Benefits and Coverage, as these services may not be covered under their policy. Enroll in 9 Months & More, Unity s prenatal and postpartum program, to receive educational materials and guidance throughout your pregnancy and the delivery of your baby. As part of the program you can sign up for text4baby, a free mobile information service that provides pregnant women and new moms with information to help them care for their health and give their babies the best possible start to life. For more information, visit and click Health & Wellness, Managing Your Health and then Pregnancy/Childbirth. Hospital Care You or a family member may require care and services in a hospital setting for non-emergency (elective/planned) surgery, treatment or tests. For elective or planned hospital services, you must use a hospital that participates in Unity s network. For all elective or planned hospital services, the admitting physician must obtain Prior Authorization from Unity for your hospital admission and stay. Note: If you are a My Choice, POS, Choice Plus, or PPO member, see pages

18 A C C E S S I N G U R G E N T & E M E R G E N C Y C A R E S E R V I C E S Accessing Urgent & Emergency Care Services Visit Health Topics at to check your symptoms to help you determine if you need urgent or emergent care. Urgent Care Services Some medical problems are not life-threatening but do need prompt attention. These include: Most broken bones Sprains Minor cuts Minor burns Non-severe bleeding Ear infections Urgent Care Centers are not emergency rooms nor a replacement for your PCP s office. When You Need Urgent Care 1. Contact your PCP first. Your PCP will tell you how to get appropriate care. Do this even when you are outside the service area. (Unity requires all participating PCPs to have 24-hour call coverage available for you.) 2. If your PCP tells you to seek care at an urgent care facility, show your Unity member ID card to the staff. 3. You must notify Unity Customer Service within three (3) business days following any urgent care treatment from an out-of-network provider. If you visit an Urgent Care Center, you will be responsible for the urgent care copayment or any deductible (refer to your Schedule of Benefits or Summary of Benefits and Coverage). In addition to a copayment or deductible, coverage for services received from an out-of-network Urgent Care Center, may be limited to usual, customary, and reasonable charges. You should work with your PCP if you need any follow-up care. If your PCP tells you to seek services somewhere other than at an urgent care facility, you will need an approved referral before you obtain care. Unity will consider payment for out-of-area urgent care services if you experience a sudden and unexpected illness or injury and all of the following are true: You urgently needed the care, AND You could not have foreseen the need for care prior to leaving the service area, AND You did not specifically leave the service area to obtain care, AND You could not have delayed care until you were able to return to the service area. Your plan will not cover care provided by out-of-area providers if you can safely return to the service area to obtain the care needed. Contact your PCP for all follow-up care. Note: If you are a My Choice, POS, Choice Plus or PPO member, see pages

19 A C C E S S I N G U R G E N T & E M E R G E N C Y C A R E S E R V I C E S Emergency Care Services An emergency medical condition is one that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any one of the following: Serious jeopardy to the person s health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child. Serious impairment to the person s bodily functions. Serious dysfunction of one or more of the person s body organs or parts. Some examples of emergencies include (but are not limited to): Heart attack Stroke Acute asthmatic attack Acute hemorrhage (bleeding) In these instances, seek emergency services at the nearest emergency facility. What To Do In Case Of An Emergency 1. Go to the nearest hospital or call 911. (Whenever possible, use a participating hospital.) 2. Have someone show your Unity member ID card to the emergency room hospital staff. 3. You must notify Unity within three (3) business days following any emergency treatment from an out-of-network provider. 4. Notify your PCP of your emergency care. Your PCP will help coordinate any necessary follow-up services. If you visit an ER, you will be responsible for the ER copay or deductible (see your Schedule of Benefits or Summary of Benefits and Coverage). You may also have other charges such as lab and X-ray charges, as the result of an ER or urgent care visit. Ambulance transportation may be subject to a copayment or deductible and coinsurance. Depending on your plan, coverage may be limited to usual, customary and reasonable charges. See your Schedule of Benefits or Summary of Benefits and Coverage and Certificate of Coverage. Note: For My Choice members, the coverage for non-contracted providers is limited to the Fee Schedule. Follow-Up Care for Urgent and Emergency Care Services Follow-up care is care you receive after the initial treatment of the urgent or emergency condition. Follow-up care is NOT urgent or emergency care. If an ER physician refers you to a specialist for a follow-up visit, call your PCP before seeing the specialist. Your PCP must provide or arrange for your follow-up care. All follow-up care must be provided within the Unity service area. Out-of-area referrals for HMO members require Prior Authorization from your PCP and approval by Unity. Note: You may have some out-of-pocket expenses if you use an emergency room or an urgent care facility. Refer to your Schedule of Benefits or Summary of Benefits and Coverage and your Certificate of Coverage for a detailed explanation of your benefits or contact Unity Customer Service. (If you are a My Choice, POS, Choice Plus, or PPO member, see pages ) 17

20 P H A R M A C Y B E N E F I T S & S E R V I C E S Pharmacy Benefits & Services Unity s formulary and a list of participating pharmacies are available at. Prescription Drug Benefit The next few pages contain information about Unity s Prescription Drug Benefit. You should also read the following documents, which provide detailed information about Unity s Prescription Drug Benefit: Prescription Drug Benefit brochure Unity s Prescription Drug Formulary Prescription Drug Benefit Rider Some Unity groups and individual plans do not have a prescription drug benefit. Refer to your new member materials or contact Unity Customer Service if you have questions about your drug coverage. Note: Pharmacy information does not apply to members covered under the State of Wisconsin Health Benefits program or BadgerCare Plus members. Prescription Drug Formulary The purpose of a formulary is to promote use of safe effective and cost-effective medications. A formulary is an important tool to help Unity meet its goal of providing coverage for safe and effective medications in an affordable manner. Unity s formulary is made up of formulary medications, a list of non-formulary medications and a list of restricted medications. Formulary medications are the most cost-effective drugs covered by Unity. Non-formulary medications are those that have suitable alternatives on the formulary or those that are considered less effective or less safe for most patients. Restricted medications are those for which you must obtain Prior Authorization from Unity before you can receive coverage. Restricted medications may be formulary or non-formulary. Excluded medications are not listed on the formulary. These are medications that your prescription benefit plan specifically excludes from coverage. Examples of commonly excluded medications include hair loss medications, sexual dysfunction medications, most over-the-counter (OTC) medications and cosmetic medications. Your specific benefit exclusions are listed in the Exclusions section of your Unity Prescription Drug Benefit Rider. 18

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