M E M B E R G U I D E. Welcome. to Unity Health Insurance

Transcription

1 M E M B E R G U I D E Welcome to Unity Health Insurance

2 Keep This Guide for Future Reference 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 Policy documents, which includes your Certificate of Coverage, Schedule of Benefits, and any Benefit Riders. If there are any differences between this Member Guide and your Policy documents, your Policy documents are the controlling documents. 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 Commercial Network Provider Directory* Medicare Select Provider Directory* (Medicare Select members only) State of Wisconsin UW Health Provider Directory* (State of Wisconsin Local and Government Participants only) State of Wisconsin Community Network Provider Directory* (State of Wisconsin Local and Government Participants only) BadgerCare Plus Provider Directory* (BadgerCare Plus Participants only) Certificate of Coverage Riders (if applicable) Schedule of Benefits or Summary of Benefits and Coverage It s Your Choice materials (State of Wisconsin and Local Government Participants only) Most of the information in this Member Guide pertains to all Unity members; however, POS and PPO members will also find information that applies just to them on pages Unity Health Insurance Customer Service If you have any questions about your benefits, send a message to Unity Customer Service through MyChart at unitymychart.com. You may also call (800) Our representatives are available weekdays from 7 a.m. to 7 p.m. is checked during normal business hours. (800) (toll-free) (608) (local) (608) (fax) (608) (hearing impaired) Pharmacy Services: (800) 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 and chat during normal business hours. Unity customer service representatives will gladly assist you in getting answers to your health care coverage questions. Other Sources of Information Read our quarterly newsletter, Pulse, for updates to this guide. Visit unityhealth.com/members for information on the following topics How to Get Care How Insurance Works Pharmacy Benefits Programs and Policies Choice90 Choosing a Pharmacy Find A Doctor Interactive look-up of Unity providers Health & Wellness Preventive Health Managing Your Health Asthma Emotional Wellness Diabetes Health Appointment Planning Health Coaching High Blood Pressure Living Well with Chronic Conditions Lower Back Pain Medication Adherence Pregnancy & Childbirth Tobacco Cessation Wellness Rewards Interactive Tools MyChart, secure online portal that gives you access to View benefit information Check claims status Contact a customer service representative Receive electronic Explanation of Benefits (EOB) 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 Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace. Unity Health Insurance does not discriminate on the basis of basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. * Providers are independent contractors and not employees of Unity Health Plans Insurance Corporation.

3 Contents 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 9 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 12 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 15 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 17 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 Choice90 Extended Supply Program Specialty Pharmaceuticals Program Half-Tab Program RX Outcomes Refill Policies 21 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 POS Member Information 27 Information for PPO Members How the PPO Plan Works PPO Member Information 28 Member Rights & Responsibilities Special Needs Complaints and Grievance Resolution Member Rights Member Responsibilities Confidentiality and Privacy Policies Women s Health and Cancer Rights Act 32 Quality Improvement Programs NCQA Accreditation HEDIS Reporting Member Satisfaction Evaluation of New Medical Technology Ensuring Quality Practitioners and Providers 34 Glossary of Commonly Used Managed Care Terms If you need language assistance, please see the contact information below. unityhealth.com 1

4 Welcome to Unity Health Insurance Welcome to Unity Health Insurance. Our goal is to keep our members healthy while managing the cost of care. We provide programs and services to meet your health care needs. We work to provide you with attentive service and access to quality care through our large network of participating providers. We strive to offer convenient access to health care within our service area. 2 unityhealth.com

5 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 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 25. PPO Plan The PPO Plan allows members to access care from providers throughout the United States. See page 27 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 unityhealth.com for more information about these plan types. unityhealth.com 3

6 Understanding the Concept of Managed Care 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 Health Insurance works with its network of providers to help 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 help keep you and your family healthy. 4 unityhealth.com

7 Enrollment and Eligibility Information New Member Enrollment Information You will receive your new member materials when you enroll. This includes your ID cards and other information about using your health plan including how to access information online at unityhealth.com. We encourage you to read your enrollment information thoroughly. Please note that in the future you will receive a letter with information directing you to MyChart to review your Schedule of Benefits (SOB) or Summary of Benefits and Coverage (SBC.) You can always contact Customer Service to request free, printed copies. If you misplace an item or have questions, log into MyChart or contact Customer Service. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice materials for more information. Your Subscriber / Member Identification Card (ID Card) Your new member information 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, login to unitymychart.com or call (800) MyChart allows you to print your ID card or you can request a new one be mailed to your home. Your new ID cards will be sent to you within five to seven business days. Unity Health Insurance 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. unityhealth.com 5

8 Enrollment and Eligibility Information The front of your Unity Health Insurance member ID card includes the following information Your Network Use this to search for providers at unityhealth.com/findadoctor: Individual Health Insurance member ID cards will indicate BeloitOne, Elite or Prime in the Your Network section of the HMO ID card. 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 and Personal Options member ID cards will indicate Unity in the Your Network section of the HMO ID card. HMO member ID cards will indicate Unity, Beloit One, Elite or Prime in the Your Network section of the HMO ID card. PPO member ID cards will indicate MultiPlan PHCS or HealthEOS Plus+ in the Your Network section. BadgerCare Plus member ID cards will indicate BadgerCare Plus in the Your Network section. Subscriber Name Full name of the subscriber. Subscriber # The subscriber number is a unique number assigned to each individual subscriber. Group # The group number identifies the subscriber s employer group and is usually the same for all members and their dependents within that employer group. 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 Health Insurance 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 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 (if applicable). 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 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 / Individual 840 Carolina Street Sauk City, WI HOW TO OBTAIN CARE BENEFIT INFORMATION: Can be found within MyChart at unityhealth.com. Simply request an account at unitymychart.com. PROVIDER NETWORK: Please use Find a Doctor at unityhealth.com. PRIOR AUTHORIZATION: Your participating doctor, hospital staff or provider must call Unity Customer Service. You are responsible for this notification when using an out-of-network provider. Please use the Prior Authorization list at unityhealth.com for further information. 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. Notify Unity Customer Service. Customer Service (800) TDD (608) Fax (608) unityhealth.com Members Send Claims to: Unity Health Insurance PO Box 610 Sauk City, WI For members with Unity drug coverage, pharmacies may use: BIN# PCN#/Rx Group# hour pharmacy: (800) This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation Front Back 6 unityhealth.com

9 Enrollment and Eligibility Information POS Point of Service (POS) Your Network: 840 Carolina Street Sauk City, WI HOW TO OBTAIN CARE 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. 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 have additional costs and you will be responsible for obtaining Prior Authorization. PROVIDER NETWORK: Please use Find a Doctor at unityhealth.com. PRIOR AUTHORIZATION: Your participating doctor, hospital staff or provider must call Unity Customer Service at least three days prior to any non-emergency hospitalization. You are responsible for this notification when using an out-of-network provider. BENEFIT INFORMATION: Benefit information is available within MyChart. 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. PHARMACY: For members with Unity drug coverage, pharmacies may use: BIN# PCN#/Rx Group# Unity 24-hour pharmacy: (800) Customer Service Send Claims to: (800) Unity Health Insurance TDD (608) PO Box 610 Fax (608) Sauk City, WI unityhealth.com This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation Front Back PPO Your Network: Subscriber Name Subscriber # Group # Your Network: Subscriber Name Subscriber # Group # Member Name Person Code Member Name Person Code 840 Carolina Street Sauk City, WI HOW TO OBTAIN CARE 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. For after hours care, contact your PCP clinic. Your clinic is required to provide you with instructions for after-hour care. If you use out-of-network providers, you 840may Carolina incur Street additional costs and you will be responsible for obtaining Sauk Prior City, Authorization. WI PROVIDER NETWORK: For care OUTSIDE of Wisconsin, call PHCS at (866) HOW TO OBTAIN CARE For care IN Wisconsin, call MultiPlan URGENT at (888) AND EMERGENCY CARE: If you have a serious medical You may also use Find a Doctor at problem unityhealth.com where care clearly cannot be delayed, call 911 or obtain care from PRIOR AUTHORIZATION: To view the a nearest list of services medical requiring site. If you Prior are unsure of the urgency of the situation, Authorization, please visit unityhealth.com. call your primary You are care responsible clinic for for instructions. this For after-hours care, contact notification when utilizing any provider. 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 have BENEFIT INFORMATION: Benefit additional information costs is and available you will within be responsible MyChart. for obtaining Prior Authorization. Simply request an account at unitymychart.com. An activation code will be PROVIDER NETWORK: For care IN Wisconsin, call HealthEOS at mailed to your home. Once you receive your activation code, follow the (800) instructions to activate your account. For care OUTSIDE of Wisconsin, call MultiPlan at (888) PHARMACY: For members with Unity You may drug also coverage, use Find pharmacies a Doctor at may unityhealth.com use: BIN# PRIOR PCN#/Rx AUTHORIZATION: Group# To view a list of services requiring Prior Unity 24-hour pharmacy: (800) Authorization, please visit unityhealth.com. You are responsible for this Customer Service notification Send when Claims utilizing to: any provider. (800) HealthEOS by Multiplan BENEFIT INFORMATION: Benefit information is available within MyChart. TDD (608) PO Box 6090 Simply request an account at unitymychart.com. An activation code will be Fax (608) De Pere, WI unityhealth.com mailed Fax to your (262) home Once you receive your activation code, follow the instructions EDI Payor to activate # (Emdeon): your account PHARMACY: 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 Customer proof Service of eligibility Send Claims to: Unity Health Plans (800) Insurance Corporation HealthEOS by Multiplan TDD (608) PO Box 6090 Fax (608) De Pere, WI unityhealth.com Fax (262) EDI Payor # (Emdeon): This card is for identification purposes only and does not constitute proof of eligibility Unity Health Plans Insurance Corporation Front Back unityhealth.com 7

10 Enrollment and Eligibility Information Changes to Your Enrollment Information If your enrollment status changes, you must contact Your employer s Benefits Administrator / Human Resources Manager if you are on a group plan Unity Health Insurance Customer Service if you purchased an individual plan directly from Unity HealthCare.gov if you purchased an individual plan through the Health Insurance Marketplace (HIM). 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 (800) * Choosing or changing your PCP See Accessing Primary Care, page 9. Your marriage As the policy subscriber, you must add your spouse to your policy within 31 days if you re on a group plan and 60 days if you re on an individual plan 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 or calling Customer Service (800) If you do not add your spouse within the timeframe specified in your plan, your spouse may be subject to a waiting period.* New baby Enroll your newborn under your policy within 60 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 Customer Service 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 Customer Service 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. You may be able to remove them from your policy by logging into MyChart. If not, contact Customer Service at (800) * Death of a member Contact Customer Service 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: materials 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 Customer Service for details.* Adult children Your adult child is eligible for coverage under your plan until age 26 or if the child is a full time student and was under 27 years of age when called to federal active duty. This only applies if he / she was a full time student when called to active duty and returned to full time student status within 12 months after fulfilling his / her active duty. Contact Unity Customer Service for further details. Disabled dependents Intellectually or physically disabled dependents may be eligible to continue coverage under your policy. Contact 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 Customer Service. To inform us of other coverage, please complete the Other Insurance Questionnaire at unityhealth.com/memberforms by selecting Other Insurance Questionnaire. 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. *Individuals who bought their health plan through the Health Insurance Marketplace (HIM) must contact them directly with these changes. 8 unityhealth.com

11 Accessing Primary Care How to Obtain Information About Practitioners and Providers The Unity Health Insurance provider directories list participating primary care physicians (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 unityhealth.com for more information about the PPO network. Our online Find A Doctor feature allows you to search for providers by their name, city, specialty type or facility. Visit unityhealth.com/findadoctor. Why Choose a 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: 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 PCP and Unity. Your PCP should Know your medical history and help 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 unityhealth.com 9

12 Accessing Primary Care How to Choose Your PCP All Unity Health Insurance 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 unityhealth.com/findadoctor or contact Customer Service. You should verify the PCP you select is accepting new patients. You can call the clinic directly, visit unityhealth.com/findadoctor or contact 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 (800) weekdays from 8 a.m. to 5 p.m. You can also send an to patient.resources@uwmf.wisc.edu. 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: PPO members please see page 27. 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 PCP, sign up for MyChart to view portions of 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 (800) 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 (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. 10 unityhealth.com

13 Accessing Primary Care 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 15 for more information on urgent / emergent care. 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 15 and 16 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 16 for more information. Vacation When on vacation you may need to access emergency or urgent care. You should follow the steps on page 15 and 16. 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 of the Unity Health Insurance service area can receive coverage for non-emergency and non-urgent care that is medically necessary and prior authorized. All non-emergent care must be prior authorized through Unity Medical Management at (888) 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 percent 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 unityhealth.com/findadoctor or the front of your provider directory for more information about the providers available to you. Out-of-area care is limited to usual, customary and reasonable charges. POS 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 wellchild 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 unityhealth.com/preventive. You can also request a paper copy by calling (800) unityhealth.com 11

14 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 Health Insurance 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 Policy documents. Note: State of Wisconsin and Local Government Participants should refer to the It s Your Choice materials 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 Customer Service to see if your plan requires Prior Authorization. Note: If you are a POS or PPO member, see pages Procedures and Equipment Requiring Prior Authorization Some medical procedures and equipment require Prior Authorization. This means that in order for the procedures or equipment to be covered, your physician must obtain approval from Unity. On the next page you will find a list of categories requiring Prior Authorization. For a complete list of services that require Prior Authorization, please visit unityhealth.com/priorauth or contact Unity Customer Service. Note: POS members are responsible for obtaining Prior Authorization for services received from an out-of-network provider. PPO members, please visit unityhealth.com 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. 12 unityhealth.com

15 Accessing Specialty Care Members will need Prior Authorization (PA) for procedures that fall into these categories Cosmetic procedures Durable Medical Equipment Experimental and Investigational Treatments Genetic Testing including Pharmacogenetics Testing Home Health Care including home infusion services Hospice Care Inpatient Admissions Out-of-Network services or supplies Pharmacy / Medications Surgical Procedures Therapies Other Therapies TMJ Surgical Treatment Transplants Uvulopalatopharyngoplasty / Somnoplasty / Uvulectomy LAUP Laser assisted uvulopalatopharyngoplasty / somnoplasty Warm Water Therapy X Stop Interspinous Implant See a full list at unityhealth.com/priorauth Pharmacy Prior Authorization is required for some clinic-administered injectable medications. Visit unityhealth.com/priorauth for the list. Dental / Oral Surgery, Optometric, Chiropractic and OB / GYN Review your Schedule of Benefits (SOB) or Summary of Benefits and Coverage (SBC) for specific coverage information for these services or contact 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 should review their Policy documents, as these services may not be covered under all policies. Behavioral (Mental Health / AODA) Health Care Services Unity Health Insurance members can seek services with a participating mental health or alcohol and other drug abuse (AODA) practitioner without a referral from their PCP. Unity s network includes psychiatrists, psychologists, licensed clinical social workers, licensed professional counselors, certified addiction counselors and specialty facilities to meet your behavioral health care needs. Note: There are certain practitioner limitations for mental health or AODA services. Members in need of behavioral (mental health care / AODA) health care services can call UW Health Behavioral Health Care Management at (800) for assistance in getting an appointment with a behavioral health practitioner. UW Health Behavioral Health Care Management connects 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 should review their Policy documents, as these services may not be covered under all policies. unityhealth.com 13

16 Accessing Specialty Care For emergency care that is life threatening, please call 911. If your need is not life threatening and you have a behavioral health provider, please call your provider s office. They will assist you. If do not have a behavioral health provider please call UW Health Behavioral Health Care Management at (800) for assistance. 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 should review their Policy documents, as these services may not be covered under all policies. Enroll in 9 Months & More, the Unity Health Insurance 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 unityhealth.com/pregnancy. 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 POS or PPO member, see pages unityhealth.com

17 Accessing Urgent and Emergency Care Services 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. Visit unityhealth.com/healthtopics to check your symptoms to help you determine if you need urgent or emergent care. 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 Health Insurance 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 member ID card to the staff. 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 (SOB) or Summary of Benefits and Coverage (SBC)). 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 from Unity, before you obtain care that is covered by Unity. unityhealth.com 15

18 Accessing Urgent and Emergency Care Services Unity Health Insurance 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 POS or PPO member, see pages 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) 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 member ID card to the emergency room hospital staff. 3. Notify your PCP of your emergency care. Your PCP will help coordinate any necessary follow-up services. If you visit an emergency room (ER), you will be responsible for the ER copay or deductible (see your Schedule of Benefits (SOB) or Summary of Benefits and Coverage (SBC)). 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 Policy documents for additional information. 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 Policy documents for a detailed explanation of your benefits or contact Unity Customer Service. (If you are a POS or PPO member, see pages ) In these instances, seek emergency services at the nearest emergency facility. 16 unityhealth.com

19 Pharmacy Benefits and Services Prescription Drug Benefit The next few pages contain information about the Unity Health Insurance 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 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. The Unity Health Insurance formulary and a list of participating pharmacies are available at unityhealth.com/pharmacy 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-preferred medications and a list of restricted medications. Formulary medications are cost-effective drugs covered by Unity. Formulary medications can either be generics (Tier 1) or brand (Tier 2) Non-preferred medications are either Brand or Generics and covered at Tier 3. Non-preferred medications are those that have suitable alternatives on the formulary or those that are considered less effective or less safe for most patients. Non-formulary Medications that are not covered. Restricted medications are those for which you must obtain Prior Authorization from Unity before you can receive coverage. Restricted medications may be preferred or non-preferred. 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 or your Certificate of Coverage. unityhealth.com 17

20 Pharmacy Benefits and Services How is the Formulary Developed? The Unity Health Insurance Pharmacy & Therapeutics (P&T) Committee is responsible for creating and maintaining the prescription drug formulary. The committee is made up of physicians and pharmacists who provide care for Unity members in our community. The P&T Committee meets monthly to review medications and determines the formulary status and restriction status of each medication. They consider a variety of factors such as safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form, appropriate uses and cost-effectiveness. To view the drug formulary, visit unityhealth.com/formulary. Medication Prior Authorization Some medications on Unity s Prescription Drug Formulary, as denoted with PA, require an approved Prior Authorization prior to coverage through Unity. To see which medications need Prior Authorization, refer to Unity s formulary. To request Prior Authorization, members, providers or authorized representatives can send request via the web, fax, mail or telephone. Unity strongly recommends that you ask your health care practitioner to initiate the prior authorization request process on your behalf. This is because your healthcare practitioner will be able to include the medical history necessary for us to make a timely decision based on all of the relevant information. Requests are reviewed by pharmacists based on criteria set by the P&T Committee. You and your practitioner will receive written notification of the decision. If your Prior Authorization Request is approved, your copay will match the formulary and brand / generic status of the drug. If your Prior Authorization Request is denied, you will have no coverage for the medication under your Unity Prescription Drug Benefit. Notifications for denials will include the reasons for the denial If you would like additional details about the reasons for denial, you can call the UW Health Pharmacy Benefit Management Program staff, who manages the pharmacy program on behalf of Unity Health Insurance at (888) You can still purchase the drug with a prescription, but you will have no insurance coverage for the prescription You can also discuss with your practitioner the possibility of changing to another appropriate drug that may be covered under your Unity Prescription Drug Benefit. For more information, visit unityhealth.com/priorauth Generic Drugs A generic drug contains the same active ingredient (the specific chemical ingredient that makes the drug work) as the brand drug. It must have the same dosing and labeling as the brand drug and must meet the same standards for purity and quality. The United States Food and Drug Administration (FDA) must approve generic drugs as equivalent to the brand before allowing them to be marketed as interchangeable. Because the FDA has determined the generic to be equivalent, your pharmacist can dispense the generic version of your medication without a new prescription from your physician. Why Choose a Generic? Why would you want to choose the generic drug over the brand drug? By choosing a generic, you can save money without losing quality. Generic drugs are not advertised or marketed as much as brand drugs, so generic drugs usually cost less. This allows you to get the generic at a lower copay. Unity s Generic Substitution Policy Unity s Generic Substitution Policy states that when FDA approved equivalent generics are available, coverage of the brand product is only provided with an approved Prior Authorization. If the active ingredient is on the formulary, coverage for the generic is provided at the Tier 1 copay If a Prior Authorization has been approved, coverage for the brand is provided at the Tier 3 copay A trial of a preferred therapeutic alternative may be required before approval of brand name product with a generic equivalent If your prescription is written for the brand drug, with your permission, your pharmacist can dispense the equivalent generic product without a new prescription. The purpose of this policy is to ensure you receive an effective drug at the lowest cost Certain drugs on Unity s Prescription Drug Formulary are exempt from the Generic Substitution Policy since even slight differences between brands or brands and generics could cause differences in the effect of the drug. These medications are sometimes called Narrow Therapeutic Index medications. To see which medications are exempt from the generic substitution policy, refer to Unity s Prescription Drug Formulary. Drugs denoted with NTI are exempt. 18 unityhealth.com