2016 Provider Directory State of Wisconsin Group Health Insurance Program Community Network

2016 Provider Directory State of Wisconsin Group Health Insurance Program Community Network

TM Important Contact Information Read the instructions for using this directory and then complete this page after you have selected Primary Care Physicians (PCPs) for you and your family. YOUR PCP My PCP is: Name: Address: Phone: OTHER FAMILY MEMBERS PCPS Member s Name: PCP Name: Name: Address: Phone: Member s Name: PCP Name: Name: Address: Phone: The availability of and providers listed in this directory changes periodically. For the most up-to-date list of and providers, please visit ChooseUnityHealth.com/findadoctor and choose State / Local Community as your Network. If you have questions regarding the status of a practitioner or provider, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, chat online at ChooseUnityHealth.com or call (800) 362-3310, Monday through Friday, from 7 a.m. to 7 p.m. (CST). Please contact individual clinics for specific clinic hours. Practitioners and providers are independent contractors and not employees of Unity Health Plans Insurance Corporation. If you receive services from a network hospital, the hospital may arrange with physicians and other providers, who are not in Unity s network, to assist in your care. Unity encourages its network hospitals to hold these providers to Unity s standards for member billing. However, if a hospital does not require those providers to comply with Unity s standards, Unity cannot influence the manner or amounts that you may be billed by the provider. Unity does not discriminate on the basis of disability in the provision of programs, services or activities. If you need this printed material interpreted or in an alternative format or if you need assistance using any of our services, contact Unity Customer Service at (800) 362-3310 or (608) 643-1421 (TDD/TTY only). For printed information about hospital affiliations, medical group affiliations, board certifications, hospital accreditation, gender of each practitioner, languages spoken by practitioner as well as an explanation of each item listed above, its source, any limitations and how often this information is validated, please send a message to Unity Health Insurance Customer Service through the message center within MyChart at unitymychart.com, chat online at ChooseUnityHealth.com or call (800) 362-3310. If you need assistance, please see the contact information below. Unity Health Insurance Customer Service (800) 362-3310 (toll-free) (608) 644-3430 (local) (608) 643-1421 (TDD/TTY only) (608) 643-2564 (fax) MyChart Member Advocate Web Site unitymychart.com (800) 362-3309 (toll-free) ChooseUnityHealth.com ChooseUnityHealth.com

Welcome to Unity Health Insurance As a managed care organization, Unity s goal is to help its members be healthy while managing the quality and cost of their care. To do this, Unity works with a large network of providers who are committed to providing quality health care services ranging from preventive care to specialty care. This member information and provider directory will give you the information you need to Choose a Primary Care Physician (PCP) Access specialty care Understand the basics of managed care Become familiar with your health insurance benefits Be a wise health care consumer Learn how Unity Customer Service can assist you with your benefit questions In addition, Unity understands that medical terminology can be confusing. That s why we ve included a detailed glossary to explain some of the medical terminology and abbreviations used throughout this directory. Through ChooseUnityHealth.com, Unity Health Insurance s website for State of Wisconsin Group Health Insurance Program and Wisconsin Public Employer Group Health Insurance Program participants, you have access to MyChart, a secure online tool where you can access benefit and claim information, receive electronic explanation of benefits (EOBs), take an online health risk assessment (HRA) and more. Plus, if you receive care from a UW Health provider you can access portions of your medical information and communicate with your health care team. Sign up for an account today at unitymychart.com Find a Doctor, Unity s provider search function, provides the most up-to-date listing of Unity s and / or providers Wellness programs, including Unity s Fitness First & More and the State of Wisconsin Group Health Insurance Well Wisconsin program, that offer incentives for making healthy lifestyle choices Health information, such as the Preventive Health Care Guideline, Unity s health management programs, including our 9 Months & More program for pregnant and post-natal women and our chronic conditions education and support services Links to other helpful web sites, including the Department of Employee Trust Funds (ETF) and information about pharmacy and dental benefits To make the most of your health benefits, we encourage you to read through this directory along with your Unity Member Guide and the It s Your Choice materials. Read on to learn more! i Welcome to Unity Health Insurance ii Map of Community Network Service Area iii Using the Community Network Provider Directory Primary Care Physicians (PCPs) Why choose a Primary Care Physician (PCP)? Steps to follow to Select a PCP Tips for Selecting a PCP Changing Your PCP v Understanding Managed Care What is Managed Care? What are the Benefits of Managed Care? What is Medical Management? Complex Case Management vii Member Services Unity s Member Promise Unity Customer Service Your Unity Health Insurance Member Identification Card Unity s Web Site and MyChart Community Provider Network ix Health and Wellness xiii Benefits: What s Covered? Medical Benefits Dental Benefits State Employees Dental Benefits Local Government Participants Durable Medical Equipment Pharmacy Services Referral Request Process Procedures and Equipment Requiring Prior Authorization Behavioral Health xxii Accessing Urgent and Emergency Care Urgent Care Emergency Care Services Accessing Care Away from Home (Out-of-Area Care) xxiv Being a Wise Health Care Consumer Know Your Benefit Plan Member Rights and Responsibilities Member Confidentiality and Privacy Policies Complaint and Grievance Procedures xxvi Special Needs xxviii Map of PCP Locations 1 PCPs 11 Facilities 15 Specialists 78 Glossary of Medical Terms 81 Index of Providers ChooseUnityHealth.com i

2016 Community Network Service Area for State and Local Government Participants 2016 Community Network Service Area (Also includes Cambridge and Mazomanie in Dane County) ii ChooseUnityHealth.com

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

Using The Community Network Provider Directory Steps to Follow to Select a PCP Now you re ready to follow these steps to select a PCP and determine which specialists you can access Step 1 If you are currently seeing a PCP, check the index in the back of this directory to determine if your PCP is a Unity participating physician in the Community Network. If the physician is listed in the index, find the page number and verify that he / she is a PCP. If you are currently seeing specialty, you should also verify that they are listed in the directory. Step 2 If you do not have a Unity PCP, determine which PCP location works best for you. Next, select a PCP from the clinic list. If you are not familiar with the PCPs at the clinic you select, you can simply list the name of the clinic and Unity will assign an available PCP or you may contact the clinic to discuss which PCP would best meet your needs. If you do not list either a PCP or a PCP clinic, Unity will assign one to you. Each member of your family can have a PCP at a different clinic within the network you select. If you are looking for a PCP at a UW Health clinic write Welcome where you put your PCP choice. You may also contact the UW Health Welcome at (800) 552-4255 Monday through Friday from 8 a.m. to 5 p.m. or you can send an email to patientresources@uwmf.wisc.edu. As a new Unity Health Insurance member and a new UW Health patient the UW Health Welcome will Help you select a new PCP Work with you to transfer your medical records from your previous health system Discuss any chronic and / or preventive issues or needs you may have Help you schedule any appointments if there is an immediate need Remember, you must seek specialty care from specialty providers listed in this directory to obtain coverage under your Unity benefits. See the information on this page for changing your Unity-Community PCP. Step 3 Be sure to thoroughly read the first page of the PCP section in this directory. It provides information about the providers available to you. If you have questions regarding participating providers or your health benefits, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, chat online at ChooseUnityHealth.com, or call (800) 362-3310, Monday through Friday 7 a.m. to 7 p.m. (CST). (See page xxii for emergency and urgent care information.) Tips for Selecting a PCP It is important to choose your PCP with care. PCPs are trained to serve as your main doctor over the long term. They provide your medical care and help you stay healthy. Look for a PCP who z Is highly recommended by your friends, family or coworkers z Has the training and background that meet your needs z Takes steps to help you prevent illness for example, helps you identify ways to stop smoking z Has admitting privileges at the hospital of your choice z Encourages you to ask questions z Listens to you z Explains things clearly so you can understand z Treats you with respect Changing Your PCP Unity provides convenient ways to change your PCP 1. Go to unitymychart.com and log into MyChart 2. Contact Unity Customer Service at (800) 548-6489 and press 2. If you have a UW Health PCP, you can change your PCP at your clinic. Since Unity and UW Health share the same database for member and patient information, you only need to notify one of us of your change. The database is automatically updated so both of us are informed at once. For the most up-to-date list of and providers visit ChooseUnityHealth.com/findadoctor. iv ChooseUnityHealth.com

Understanding Managed Care What is Managed Care? Managed care is designed to help keep members healthy. Managed care empowers members to seek preventive health care services and to work with their PCP to make the appropriate health care choices. Managed care consumers have rights and responsibilities to assure they receive quality care and services. This includes the right to choose a PCP, the right to privacy and confidentiality and the responsibility for providing accurate information (see inside back cover for more information). In addition, Unity expects you as a member to be responsible for 1. Using your Unity PCP to coordinate your care 2. Contacting Unity Customer Service any time you have questions about your Unity benefits What are the Benefits of Managed Care? Unity s managed care plans promote the following Coordination of Care Your relationship with your PCP is an important one because he / she should help coordinate all your health care services. Convenient Access Unity s Community Network service area includes hospitals and clinics in Adams, Columbia, Crawford, Dodge, Fond du Lac, Grant, Green, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock, Sauk, Vernon, Waukesha and Walworth counties plus the communities of Cambridge and Mazomanie. Streamlined Administration There is very little, if any, follow-up paperwork when you seek care from a Unity participating provider. Just show your member ID card at the time of service, pay any copayment, coinsurance or deductible (if applicable) and in most instances, your practitioner will submit claims and prior authorizations on your behalf. Care Management Unity s doctors, nurses and other health professionals work with your PCP to review your care and help ensure you receive medically necessary and appropriate services. Health Education and Wellness Unity partners with UW Health and a variety of community providers to offer health education classes and services to improve your health and well-being. Visit unityhealth.com/health-wellness for more information. Preventive Health Care Unity promotes preventive health care services such as age appropriate physical exams, well-child care, routine Pap tests, mammograms and many others to help keep you and your family healthy. Unity has adopted the Preventive Health Care Guideline, based on the US Preventive Task Force, to help you plan routine care visits. This guideline includes recommendations for adults, children and pregnant women. For a copy of the guideline, visit unityhealth.com/preventive or send a message to Unity Customer Service through the message center within MyChart at unitymychart.com, chat with us online at ChooseUnityHealth.com or call (800) 362-3310. ChooseUnityHealth.com v

Understanding Managed Care What is Medical Management? Unity carefully reviews prior authorization requests and pre-certification notifications which are submitted by participating. This process of medical management, sometimes called utilization management, is conducted by experienced staff that includes registered and licensed practical nurses with the support of board certified physicians. Medical management staff work with your PCP or your treating provider to coordinate pre-service review (before care or services are delivered), concurrent review (while care or services are being provided) and post-service review (after care or services have been provided) related to your care. Unity works with participating physicians and medical management staff to help ensure decisions regarding treatment are based only on appropriateness of care and service. Unity does not reward or other individuals involved in the medical management process for issuing denials of coverage or care. Unity does not offer financial incentives or rewards for medical management decision makers to encourage decisions that result in under utilization. Complex Case Management If you have a serious or complicated medical problem, you may qualify for complex case management services. Complex case management is a process in which experienced registered nurses and licensed social workers work with both you and your doctor to coordinate, monitor and evaluate the options and services available to best meet your health care needs. Unity s complex case management staff may become involved with you if you experience a critical event or a diagnosis for a complicated problem. Your doctor may refer you to our care team or you and / or your caregiver may contact us at (888) 829-5687. In addition, you may be referred for case management through Unity s medical management processes, a treating practitioner or by a referral from one of Unity s Health Management programs. vi ChooseUnityHealth.com

Member Services Unity Health Insurance s Member Promise Providing excellent customer service is a company-wide goal at Unity Health Insurance. Every employee is dedicated to ensuring that our members have a high level of satisfaction with their Unity health insurance plan. We strive to Provide prompt and accurate member services Keep our promises and commitments to our customers Exceed our customers expectations in everything we do Unity Health Insurance Customer Service Unity is committed to member satisfaction. Unity Customer Service can assist you with any questions about your health benefits quickly. Unity Customer Service can be reached by sending a message through the message center within MyChart at unitymychart.com, our online chat feature at ChooseUnityHealth.com or calling (800) 362-3310 or (608) 643-1421 (TDD / TTY only). Customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. (CST). Outside of normal business hours, you may leave a voice mail message including your name, subscriber number, telephone number where you can be reached, and the best time (any time, day or night) for a customer service representative to return your call. Unity monitors email and phone messages during normal business hours. We can serve you better if we have up-to-date information. If you have a change of address, please call (800) 548-6489 and follow the instructions regarding your changes ChooseUnityHealth.com or login to MyChart. Also, be sure to notify your Benefits / Payroll Office. Unity offers the ability to chat with a Customer Service Representative using the Internet. Our chat feature makes it more convenient to receive real time answers to your questions. To chat with us go to ChooseUnityHealth.com and select the Click to Chat icon. Your Unity Health Insurance Member Identification Card Soon after enrolling in Unity you will receive two Unity identification (ID) cards. These cards identify you (the subscriber) and your covered dependents, your group number, a PCP for each family member (if applicable) and your selected provider network. Your selected network will appear on your ID card as STATE / LOCAL COMMUNITY. If you or your family misplaced your Unity ID card you can request or print a new ID card through MyChart. Log into unitymychart.com and select Forms & Resources then Request or Print ID Cards. 123456789-00 1234567 123-456-7890 123-456-7890 123-456-7890 123-456-7890 123456789-01 123456789-02 123456789-03 vii

Member Services Unity knows that privacy is very important to you which is why your member ID number is a randomly assigned number. PLEASE READ THE IMPORTANT REMINDERS ON YOUR IDENTIFICATION CARD There is important information on the front and back of your member ID card. Do not tear it in half you will need the top and bottom portions to present at your clinic when you seek services. Always have your member ID card with you each time you access services from a participating health care provider or when calling Unity Customer Service. If you wish to change your PCP to another in the Community Network, notify Unity Health Insurance. You will be issued new cards with the revised information on them. Any time you are issued new cards, please destroy the old cards. Any inquiries about member ID cards can be directed to Unity Customer Service at (800) 362-3310 or TDD / TTN (608) 643-1421. Signup for MyChart Today! MyChart, located at unitymychart.com, is a secure online service that provides a convenient way for you to view your Unity insurance information and portions of your UW Health medical information, if you have a UW Health medical provider. The Unity insurance information in MyChart allows you to View your benefit information Check claim status Access electronic communications including your explanation of benefits (EOB) Check eligibility for yourself and your dependents Review prior authorizations Request or print ID cards Access easy-to-use tools and resources like health risk assessments (HRA) Change your Primary Care Physician (PCP) Ask a question using the Send a Message feature Members with a UW Health medical provider can Receive test results online Schedule, cancel and view appointments View and print information about selected health issues, medications, allergies and immunizations Send secure electronic messages to your health care team Access billing information View information for your children. (All features are available for children ages zero to 11. For children ages 12 to 17 access is restricted to information about allergies, immunizations, sending messages and scheduling appointments. You cannot review appointments for children ages 12 to 17.) Receive quick care for some health problems with an e-visit ChooseUnityHealth.com Through Unity Health Insurance s website for State of Wisconsin and Local Government participants, you also have access to Healthwise Knowledgebase (A-Z Health Topics) to answer your medical questions Find a Doctor, a provider search function that allows you to create customized provider directories Health information such as a Preventive Care Guideline and Unity s health management programs Unity s wellness program, Fitness First & More Unity s Member Guide a comprehensive primer on managed care Links to the websites for Wisconsin Department of Employee Trust Funds (ETF) Navitus Health Solutions Delta Dental Unity s Member Confidentiality Notice And much, much, more! Community Provider Network Unity s Community Network includes 36 hospitals and over 150 clinics participating in Adams, Columbia, Crawford, Dodge, Fond du Lac, Grant, Green, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock, Sauk, Vernon, Waukesha and Walworth counties plus the communities of Cambridge and Mazomanie. To find out if your practitioner or hospital is a Community Network provider Visit ChooseUnityHealth.com/findadoctor Call Unity Customer Service at (800) 362-3310 Review the provider listings in this directory. viii ChooseUnityHealth.com

Health and Wellness Well Wisconsin Well Wisconsin is a wellness program that promotes personal health and well-being. Every adult on your state health insurance plan can participate in Well Wisconsin, including your spouse, domestic partner and adult children who are 18 years and older. When you complete Unity s online Health Survey through Unity s MyChart and complete a Wellness Assessment at an on-site Well Wisconsin screening event at your workplace, you are eligible to receive a $150 incentive check from Unity.* You can also get your wellness screening at your physician s office. The online Health Survey is a short questionnaire about your health habits. It will highlight healthy habits and suggest areas for improvement. You can complete the Health Survey at ChooseUnityHealth.com by logging into MyChart and selecting Get Started under Well Wisconsin. The Wellness Assessment will measure your blood pressure, cholesterol level, glucose and height / weight. You can complete the Wellness Assessment at a Well Wisconsin screening event held at your employer s location or by completing the 2016 Wellness Assessment Exception form, located on the Well Wisconsin website or within MyChart, with verifiable information from your physician. For more information about Well Wisconsin and to find the schedule for on-site Wellness Assessments visit wellwisconsin.wi.gov. * Please note all health and wellness rewards and reimbursements paid to adult members are considered taxable income to the subscriber and Unity is required to report these to your employer. Health information, including your responses to the Health Survey, is protected by federal privacy laws and will not be shared with your employer. ChooseUnityHealth.com ix

Health and Wellness Fitness First & More Fitness First & More incorporates exercise, nutrition, weight loss and other activities to give you a well-rounded approach to your health and wellness goals whether you want to lose weight, eat better or reduce your stress level. Plus, by participating in Fitness First & More you can receive rewards for taking steps toward leading a healthy lifestyle. How You Can Earn Your Rewards / Reimbursements Through Fitness First & More Fitness First & More offers a maximum $200 reward / reimbursement per calendar year.* Here are the ways you can earn it. Single Coverage Family Coverage About the Fitness First & More Program As a member of Fitness First & More, you can participate in a variety of different activities, including Fitness First Exercise at a participating health club 60 times in six consecutive months and earn a reward. Health Education Classes Take a health education class at any Unity participating hospitals, clinics or other approved vendors and get reimbursed. Integrative Medicine Receive a reimbursement for integrative medicine services like acupuncture, Feldenkrais, Healing Touch, massage therapy or Bodywork from UW H ealth Integrative Medicine specialists, Fitness First approved health clubs or Health First vendors. Weight Management Attend Weight Watchers meetings, participate in Weight Watchers online or participate in Diet Free and be reimbursed. Community Supported Agriculture Purchase a qualifying produce share from a member FairShare Community Supported Agriculture Coalition farm and get reimbursed. Unity is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all members. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at (800) 362-3310 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. Health First Health First provides discounts on products and services that help create positive changes in a member s personal health. Discounts are available on eyeglasses, massage therapy, sports equipment and more! Fitness First for Kids Fitness First for Kids is an exercise reward program for kids between the ages of 5 and 18 who are insured dependents of a Unity subscriber. Kids can earn prizes for being physically active a minimum of 30 minutes a day. To learn more about this program go to unityhealth.com/fitnessfirstkids. * Please note all health and wellness rewards and reimbursements paid to adult members are considered taxable income to the subscriber and Unity is required to report these to your employer. Health information, including your responses to the Health Survey, is protected by federal privacy laws and will not be shared with your employer. x ChooseUnityHealth.com

Health and Wellness Preventive Health Programs Immunization Programs Childhood vaccines prevent many infections that can affect children, adolescents, and adults. Unity has several immunization initiatives in place, including Childhood Immunizations Reminder mailing to parents at 10 months: Varicella (chickenpox) reminder 12 months: Immunization schedule from CDC for birth until six years old 19 months: Fill-it-in & Win brochure Fill-it-in & Win Incentive Program Reward program for two year olds who have completed CDC recommended vaccines Adolescent Immunizations Reminder immunization schedule from CDC for seven to 18 year olds 12 years old (sent in the month of the member s 12th birthday) HPV reminder letter sent to members who have received first or second vaccination, to schedule second or third vaccination Breast Cancer Screening Program A potentially deadly disease like breast cancer is highly curable when caught in the early stages. Unity strives to remind our female members of the importance of preventive screenings. We send reminders to female members who are past due for their screening, as well as a reminder to their primary care physician. In addition, as members turn 40 and 50 years of age we send a letter and educational brochure to help them remember to schedule a mammogram. Cervical Cancer Screening Program Cervical cancer, like breast cancer, is highly curable when caught in the early stages. Because getting a Pap test is so important, we send reminders to all age appropriate women who are past due for this service as well as a reminder to their primary care physician. In addition, as members turn 18, 40 and 50 years of age, we send a letter and educational brochure to help them remember to schedule a Pap test. Preventive Health Care Guideline Unity has adopted a Preventive Health Care Guideline so members can plan routine care visits to keep healthy. The guideline contains preventive service recommendations for infants, children, adolescents, adults and women thinking of becoming pregnant. Smoking Cessation Program Smoking is the single most preventable cause of death and disease in our nation, according to the s for Disease Control (CDC). Unity understands how hard it is to quit tobacco and works with our to provide the information and services to help their patients quit. State and Local Government participants are eligible to receive six consecutive 30-day supplies per calendar year of pharmacotherapy (which requires a written prescription from a physician) that can help tobacco users quit. We also provide tobacco cessation resources to help the tobacco user get connected with personnel trained for support in quitting. Health Management Programs For more information about any of the following Health Management programs, call toll-free (866) 884-4601. Asthma Unity has developed a unique program to support members who have asthma. Our program concentrates on education, improving self-management skills and encouraging strong partnerships between patients and their. Regular services include annual flu vaccine reminder and informational mailings with tools and tips for managing asthma. Diabetes Unity has many initiatives to help members control their diabetes, such as a guideline for living with diabetes, a diabetes self-management magazine, reminders about screenings to prevent complications of diabetes, such as annual dilated eye exam and annual flu vaccine. Depression Unity has developed a program for members with chronic, situational or postpartum depression. Participating members will receive periodic educational mailings. Hypertension For members with high blood pressure Unity has developed a hypertension program. If you have other conditions, such as diabetes, high cholesterol or chronic kidney disease, you will be sent periodic mailings about high blood pressure. In addition, your practitioner will receive reminders when lab tests are due. 9 Months & More Unity s 9 Months & More program provides education and guidance to help you through your pregnancy and the delivery of your baby. It is available to all Unity members who are pregnant. The program runs from the time you are identified as being pregnant until two months after you deliver. You will receive information about the stages of your pregnancy, a contact from our Quality Care Coordinator each trimester, an optional free health and safety text message program and a postpartum gift* upon successful completion of the program. * Please note all health and wellness rewards and reimbursements paid to adult members are considered taxable income to the subscriber and Unity is required to report these to your employer. Health information, including your responses to the Health Survey, is protected by federal privacy laws and will not be shared with your employer. ChooseUnityHealth.com xi

Health and Wellness Patient Safety Patient safety continues to be a growing concern and health care challenge for our country. A part of the solution is for, hospitals, clinics and health plans to continue to improve upon standards of care. These improvements include reducing errors during surgery, decreasing inpatient mistakes, improving accuracy in prescriptions to make them clearer and clarifying treatment plans for patients. Patients, like you, are encouraged to take an active role in staying safe while under medical care. Asking questions and talking openly and honestly with your can help you avoid dangerous mistakes. A checklist to help you prepare for your appointments is available at unityhealth.com/appointmentplanning. Unity has encouraged its participating hospitals, both in urban and rural areas, to complete and submit information to Leapfrog, an organization that gathers and reports information on hospital quality and patient safety efforts. Unity also encourages hospitals to submit survey information to the Wisconsin Hospital Association s (WHA) CheckPoint. CheckPoint gathers and reports information about safety and quality improvement programs from medical clinics and hospitals throughout the state. Results of these initiatives are available by visiting leapfroggroup.org and wicheckpoint.org. What You Can Do One of the most important ways to stay safe and healthy is to treat your practitioner as a partner in your health care. Here are some tips to help keep you safe 1. Ask questions and get explanations when you don t understand your health care practitioner. 2. Be open and honest when your practitioner asks you questions. 3. Keep a list of all the medications you are taking. Know the dose and purpose of each medication. 4. Check your prescription when you pick it up from the pharmacy. 5. Know what tests are being done, why they are being done and the risks and anticipated results. 6. Openly discuss all of your treatment options with your practitioner, do not be afraid to ask for a second opinion. 7. Talk to everyone who is providing your care. 8. Bring a family member or friend to your appointment; during a stressful situation, it helps to have another person present. 9. Make sure everyone who handles your care in the hospital checks your identification bracelet for information. 10. Educate yourself about your condition. Patient safety begins with you, the patient. Standards designed by the health care industry and patient safety groups not only hold health care professionals responsible, but should assist you in being a more active and informed member of your health care team. If you are interested in learning more about any of Unity Health Insurance s Health and Wellness programs, requesting additional information is easy. You can Visit unityhealth.com/health-wellness Call Unity Customer Service at (800) 362-3310 xii ChooseUnityHealth.com

Benefits What s Covered? The Schedule of Benefits is not the contract of insurance. All benefits are paid according to the terms of the Master Contract between Unity Health Plans Insurance Corporation and the Group Insurance Board. Uniform Benefits and this Schedule of Benefits are wholly incorporated in the Master Contract. The Schedule of Benefits describes certain essential dollar or visit limits of your coverage and certain rules, if any, you must follow to obtain covered services. In some situations (for example, emergency services received from a non-plan provider), benefits will be determined according to the usual and customary charge. A change to another health plan will result in all benefit maximums restarting at $0 with the exception of the prescription annual out-of-pocket limit. This does not include dental and orthodontia benefits that Health Plans may offer due to illness or injury, that are not a part of Uniform Benefits. Except as specifically stated for emergency and urgent care (see Sections III., A., 1. and 2. in the It s Your Choice materials), you do not have coverage for services from non-plan providers unless you get a prior authorization approved by Unity. Prior Authorization requirements are described in the Health Plan Descriptions section of the It s Your Choice: materials. ChooseUnityHealth.com xiii

Benefits What s Covered? MEDICAL BENEFITS FOR STATE PARTICIPANTS The covered benefits that are administered by Unity Health Insurance are subject to the following Policy deductible, coinsurance and medical copayments described below Benefit State Eligible Participants who are not Medicare Prime Participants High Deductible Health Plan of Wisconsin eligible for nor enrolled in for eligible Participants 3 Medicare as the primary payor 3 Annual Medical $250 Individual / $500 Family None The Deductible must be met Deductible before coverage begins. The When an individual within a family Deductibles are: $1,500 per plan meets the $250 deductible individual plan, $3,000 per family coinsurance will apply to covered plan. Deductible includes medical services. prescription drugs and applies to Out-of-Pocket-Limit (OOPL). Medical Deductible does not apply to office visit copayments or prescription drugs. Annual Medical After Deductible: 90% / 10% 100% except as described below After Deductible: 90% / 10%. Coinsurance applies to medical services except for: durable medical equipment, applies to medical services except for office visits and as described cochlear implants and hearing aids. for office visits and as described below. Coinsurance applies to Then, 80% to OOPL. below. Coinsurance applies to Out-of-Pocket-Limit (OOPL) except OOPL except as described below. as described below. Annual Medical $1,250 Participant / $2,500 None except as described below After Deductible: $2,500 per Out-of-Pocket Limit aggregate family limit except for: durable medical equipment, individual plan, $5,000 per family (OOPL) as described below. 1 cochlear implants and hearing aids. plan except as described below. Then, 80% to OOPL. 1 Routine, preventive 100% 100% 100% services as required by federal law Primary Care Office Visit $15 Deductible need not No medical copayments. After Deductible: $15 Copayment applies to: be met first. Primary Care Office Visit. Family Practice General Practice Copayments count towards Copayment applies towards Internal Medicine meeting the annual OOPL, meeting the annual OOPL. Gynecology / but not the Deductible. Obstetrics Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy Specialist Copayment $25 per visit Deductible No medical copayments After Deductible: Applies to: need not be met first $25 per visit Specialists Urgent Care Copayments count towards Copayment applies towards meeting the OOPL, but meeting the annual OOPL not the Deductible Illness / injury related After Deductible: 90% 100% After Deductible: 90% services beyond the (10% member cost to OOPL) (10% member cost to OOPL) office visit copayment (if applicable) Emergency Room $75 copayment to OOPL. $60 After Deductible, $75 copayment Copayment (Waived After Deductible and copay to OOPL. After Deductible and if admitted as an 90% (10% member cost copay 90% (10% member inpatient directly from to OOPL) cost to OOPL) the emergency room or for observation for 24 hours or longer.) xiv ChooseUnityHealth.com

Benefits What s Covered? MEDICAL BENEFITS FOR STATE PARTICIPANTS Benefit State Eligible Participants who are not Medicare Prime Participants High Deductible Health Plan of Wisconsin eligible for nor enrolled in for eligible Participants 3 Medicare as the primary payor 3 Medical Supplies, After Deductible: 80% 80% to an annual OOPL After Deductible: 80% Durable Medical (20% member cost to OOPL) 2 of $500 per Participant; (20% member cost to OOPL) 2 Equipment and no aggregate family limit Durable Diabetic (20% member cost to OOPL) 2 Equipment and Related Supplies Cochlear Implants for After Deductible: 90% hospital 100% hospital charges. After Deductible: 90% hospital Participants age 18 charges (10% member cost to 80% device, surgery for charges (10% member cost to and older OOPL). 80% device, surgery for implantation, follow-up sessions OOPL). 80% device, surgery for implantation, follow-up sessions to train on use (20% member cost implantation, follow-up sessions to train on use (20% member does not apply to OOPL). to train on use (20% member cost does not apply to OOPL). cost to OOPL). Cochlear Implants for After Deductible: As required by 100% hospital, device, surgery for After Deductible: As required by Participants under Wis. Stat. 632.895 (16), 90% for implantation and follow-up Wis. Stat. 632.895 (16), 90% for age 18 hospital charges, device, surgery sessions to train on use. hospital charges, device, surgery for implantation and follow-up for implantation and follow-up sessions to train on use. sessions to train on use. (10% member cost to OOPL) (10% member cost to OOPL) Hearing Aids for After Deductible: 80% (20% 80% (20% member cost After Deductible: 80% (20% Participants age 18 member cost does not apply to does not apply to OOPL) member cost does not apply to and older. One aid per OOPL). Maximum health plan Maximum health plan payment OOPL). Maximum health plan ear no more than payment of $1,000 per hearing aid. of $1,000 per hearing aid. payment of $1,000 per hearing aid. once every 3 years. Hearing Aids for After Deductible: As required by As required by Wis. Stat. After Deductible: As required by Participants under Wis. Stat. 632.895 (16), 90%. 632.895 (16), 100%. Wis. Stat. 632.895 (16), 90%. age 18 (10% member cost to OOPL) (10% member cost to OOPL) Temporomandibular After Deductible: 80% 80% (20% member cost to OOPL) After Deductible: 80% Joint Disorders (20% member cost to OOPL) for for intraoral splints as Durable (20% member cost to OOPL) for intraoral splints as Durable Medical Equipment. Other services intraoral splints as Durable Medical Equipment. Other services 100%. Maximum health plan Medical Equipment. Other services 90% (10% member cost to OOPL). payment of $1,250 for diagnostic 90% (10% member cost to OOPL). Maximum health plan payment of procedures and nonsurgical Maximum health plan payment of $1,250 for diagnostic procedures treatment per Participant $1,250 for diagnostic procedures and nonsurgical treatment per per calendar year. and nonsurgical treatment per Participant per calendar year. Participant per calendar year. Dental Implants After Deductible: 90% 100% following accident or injury After Deductible: 90% (10% member cost to OOPL) up to a maximum health plan (10% member cost to OOPL) following accident or injury up to payment of $1,000 per tooth. following accident or injury up to a maximum health plan payment a maximum health plan payment of $1,000 per tooth. of $1,000 per tooth. Prescription Drugs Benefits provided by Benefits provided by Benefits provided by Navitus Health Solutions. Navitus Health Solutions. Navitus Health Solutions. After Deductible, subject to cost sharing. Under no circumstances will you pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,850 single / $13,700 family for federally required essential health benefits. 1 Level 3 prescription drug coinsurance will continue to be paid by you past the OOPL, to the federal MOOP. 2 Federally required preventive services are covered at 100%. 3 State of Wisconsin Medicare eligible annuitants and their Medicare eligible dependents are limited to participation under the Medicare Prime Uniform Benefits Schedule of Benefits. Every effort has been made to ensure information in this guide is accurate. In the event of conflicting information, federal law, state statute, state health contracts and / or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed. ChooseUnityHealth.com xv

Benefits What s Covered? MEDICAL BENEFITS FOR STATE PARTICIPANTS Lifetime Maximum Benefit on all Medical and Pharmacy Benefits None Ambulance Covered as medically necessary for emergency or urgent transfers. Diagnostic Services Limitations Prior Authorization may be required. Outpatient Physical, Speech and Occupational Therapy Maximum (includes Habilitation Services or Rehabilitation Services) Covered up to 50 visits per participant for all therapies combined per calendar year. This limit combines therapy in all settings (for example, home care, etc.). Additional medically necessary visits may be available when prior authorized by Unity, up to a maximum of 50 visits per therapy per participant per calendar year. Cochlear implants Device, surgery for implantation of the device, follow-up sessions to train on use of the device when medically necessary and prior authorized by Unity and hospital charges. The participant s out-of-pocket costs are not applied to the annual out-of-pocket maximum. As required by Wis. Stat. 632.895(16), cochlear implants and related services for participants under 18 years of age are payable as described in the preceding grid. Hearing aids One hearing aid per ear no more than once every three years payable as described in the preceding grid, up to a maximum payment of $1,000 per hearing aid. The participant s out-of-pocket costs are not applied to the annual out-of-pocket limit. As required by Wis. Stat. 632.895(16) hearing aids for participants under 18 years of age are payable as described in the preceding grid and the $1,000 limit does not apply. Home Care Benefit Maximum 50 visits per participant per calendar year. 50 additional medically necessary visits per participant per calendar year may be available when authorized by Unity. Hospice Care Benefits Covered when the participant s life expectancy is six months or less, as authorized by Unity. Transplants Limited to transplants listed in the benefits and services section of Uniform Benefits in the It s Your Choice materials. Licensed Skilled Nursing Home Maximum 120 days per benefit period payable for skilled care. Mental Health / Alcohol / Drug Abuse Services Annual dollar and day limit maximums for mental health / alcohol / drug abuse services are suspended as required by the Federal Mental Health Parity Act. Vision Services One routine exam per participant per calendar year. Non-routine eye exams are covered as medically necessary. (Contact lens fittings are not part of the routine exam and are not covered.) Oral Surgery Limited to procedures listed in the benefits and services section of Uniform Benefits in the It s Your Choice materials. Temporomandibular Disorders as required by Wis. Stat 632.895(11) The maximum benefit for diagnostic procedures and non-surgical treatment is $1,250 per participant per calendar year. Intraoral splints are subject to the durable medical equipment coinsurance (that is payable at 80%) and apply to the non-surgical treatment maximum benefit. Dental Services No coverage provided under Uniform Benefits except as specifically listed in Benefits and Services section. Pharmacy benefits are administered by Navitus Health Solutions, LLC, a pharmacy benefits manager (PBM). Members who have Medicare as their primary insurance have the Navitus Medicare Rx (PDP) plan, which is offered by Navitus Health Solutions and underwritten by Dean Health Insurance, a Federally Qualified Medicare Contracting Prescription Drug Plan. Every effort has been made to ensure information in this guide is accurate. In the event of conflicting information, federal law, state statute, state health contracts and / or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed. xvi ChooseUnityHealth.com

Benefits What s Covered? MEDICAL BENEFITS FOR LOCAL GOVERNMENT PARTICIPANTS The covered benefits that are administered by Unity Health Insurance are subject to the following Policy deductible, coinsurance and medical copayments described below Benefit: Participating WPE eligible Participants WPE eligible Participants WPE eligible Participants High Deductible Health Wisconsin Public in Program Option in PO 6 who are not in PO 4 including Plan WPE eligible PO 7 Employers (WPE) (PO) 2 and Medicare eligible for nor enrolled Medicare eligible and Participants 3 eligible and enrolled in in Medicare as the enrolled PO 6 and PO 7 primary payor 3 Annual Medical None $250 Individual / $500 Individual / The Deductible must be Deductible applies to $500 Family $1,000 Family met before coverage Out-of-Pocket-Limit begins. The Deductibles are: (OOPL) When an individual within When an individual within $1,500 per individual plan a family plan meets the a family plan meets the $3,000 per family plan. $250 Deductible coinsurance $500 Deductible coinsurance Deductible includes will apply to covered medical will apply to covered medical prescription drugs services. Medical Deductible services. Medical Deductible does not apply to office visit does not apply to office visit copayments or prescription copayments or prescription drugs. drugs. Annual Medical 100% except as described After Deductible: 90% / 10% 100% except as described After Deductible: 90% / 10% Coinsurance below for: durable medical applies to medical services below for: durable medical applies to medical services equipment, cochlear except for office visits, and equipment, cochlear except for office visits and implants and hearing aids. as described below. implants and hearing aids. as described below. Then, 80% to Coinsurance applies to Then, 80% to OOPL. Coinsurance applies to Out-of-Pocket-Limit (OOPL). Out-of-Pocket-Limit (OOPL) Out-of-Pocket-Limit (OOPL) except as described below. except as described below. Annual Medical None except as described $1,250 Participant / $2,500 After $500 per individual After Deductible: Out-of-Pocket Limit below for: durable medical aggregate family limit $1,000 aggregate per family $2,500 per individual plan (OOPL) equipment, cochlear except as described Deductible, none except as $5,000 per family plan implants and hearing aids. below. 1 described below for: durable except as described below. Then, 80% to OOPL. 1 medical equipment, cochlear implants and hearing aids. Then, 80% to OOPL. 1 Routine, preventive services 100% 100% 100% 100% as required by federal law Primary Care Office Visit No medical copayments $15 Deductible need not No medical copayments After Deductible: $15 Copayment applies to: be met first. Primary Care Office Visit Family Practice General Practice Copayments count Copayment applies Internal Medicine towards meeting the towards meeting the Gynecology / Obstetrics annual OOPL, but not annual OOPL Midwives the Deductible. Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy Specialist Copayment No medical copayments $25 per visit Deductible No medical copayments After Deductible: Applies to: need not be met first. $25 per visit. Specialists Urgent Care Copayments count towards Copayment applies towards meeting the OOPL, but meeting the annual OOPL. not the Deductible. Illness / injury related 100% After Deductible: 90% 100% After Deductible: 90% services beyond the office (10% member cost (10% member cost visit copayment (if applicable) to OOPL). to OOPL). Emergency Room Copay $60 $75 copayment to OOPL. $60 After Deductible, $75 (Waived if admitted as an After Deductible and copay copayment to OOPL. inpatient directly from the 90% (10% member cost After Deductible and copay, emergency room or for to OOPL). 90% (10% member cost observation for 24 hours to OOPL). or longer.) ChooseUnityHealth.com xvii