Your Plan Benefits

Understanding how your health insurance plan works once you’re enrolled is just as important in getting the right care as picking your benefit package.

Access your plan documents in our online Prevea360 Benefit Center, and learn more about our processes and procedures in the Understanding Your Plan section below.

Your Plan Documents
Find important documentation related to your health plan benefits—such as your certificate of coverage, Summary of Benefits and Coverage (SBC), and  member certificate or policy—by visiting the Prevea360 Benefit Center. Take Me to the Prevea360 Benefit Center

Understanding Your Plan
Expand the topics below to learn more.

Member Rights & Responsibilities

Prevea360 Health Plan members deserve the best service and health care possible. Prevea360 is committed to maintaining a mutually respectful relationship with its members. To promote effective health care, Prevea360 clearly states its expectations for the rights and responsibilities of its members, to foster cooperation among members, practitioners and Prevea360.

Members have the right to:

  • Be treated with respect and recognition of their dignity and right to privacy.
  • Receive a listing of Prevea360 participating practitioners in order to choose a Primary Care Physician.
  • Present a question or complaint or grievance to Prevea360, about the organization or the care it provides, without fear of discrimination or repercussion.
  • Receive information on procedures and policies regarding their health care benefits.
  • Timely responses to requests regarding their health care plan.
  • Request information regarding Advance Directives.
  • Participate with practitioners in making decisions about their health care.
  • A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • Receive information about the organization, its services, its practitioners and providers, and members’ rights and responsibilities.
  • Make recommendations regarding the organization’s members’ rights and responsibilities policies.

Members have the responsibility to:
  • Read and understand the materials provided by Prevea360 concerning their health care benefits. Prevea360 encourages members to contact Prevea360 if they have any questions.
  • Present their ID Card in order to identify themselves as Prevea360 members before receiving health care services.
  • Notify Prevea360 of any enrollment status changes such as family size or address.
  • Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
  • Follow plans and instructions for care that they have agreed on with their practitioners.
  • Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
  • Fulfill financial obligations as it relates to any copays, deductibles and/or premiums as outlined in your policy.

Prescription Drug Benefit

Many of our policies cover "legend" prescription drugs. These are drugs which by law require a written prescription from your doctor. You can find your drug coverage outlined in your Schedule of Benefits. Here is the information you need to understand about your prescription drug coverage.

Prescriptions Limits
Generally, Prevea360 Health Plan's policy for dispensing drugs is limited to a 30-day supply. If your plan is different it will be indicated in your Schedule of Benefits. Your Schedule of Benefits will also note if you have an annual prescription benefit maximum. Please check your Schedule of Benefits to verify what your specific policy allows.

Filling your Prescription
Your prescription may be filled at any of our plan pharmacies. Prevea360 Health Plan requires that the generic equivalent be dispensed. A generic medication contains the same ingredients and is absorbed by your body to the same extent as brand name medication.

If you are out of the service area and need to fill a prescription, you can simply go to one of the national plan pharmacies that are listed in the Provider Directory. In most cases, these pharmacies will collect the appropriate copay and bill Prevea360 Health Plan just as a local pharmacy would. This makes it easy for you, whether at home or away.

If a national plan pharmacy is not available, your prescription will be covered only if your policy has a non-plan provider benefit or if the prescription is for an urgent or emergency care situation. If you fill your prescription at a non-plan pharmacy, you will need to pay for the prescription and submit a claim to us for reimbursement in full minus any copayment.

Prior Authorization of Prescriptions
By requiring prior authorization for certain medications, we can help control escalating health care costs that affect your premiums. You may receive a list of the drugs that require prior authorization by calling our Customer Care Center. As outlined in the Member Certificate, if your physician prescribes one of these drugs, either your physician, the pharmacy or you can initiate a prior authorization request.

Occasionally, a prior authorization request may be denied. Should this occur, the requesting physician is always offered alternative drugs to prescribe that are covered by Prevea360 Health Plan.

Drug Formulary

What is a drug formulary?
A drug formulary is a list of approved drugs that are covered with a copayment by the insurance company. You can search our online formulary by drug name, category or subcategory.

Why do we use a drug formulary?
A drug formulary is a tool used by many insurance companies in an effort to standardize care, to improve the quality of care and to reduce premium costs.

How are drugs added and excluded from the drug formulary?
Prevea360 Health Plan's Pharmacy and Therapeutics committee meets regularly to review the effectiveness, safety, and costs of medications when making decisions about what to add and delete from the drug formulary.

Can an exception be made?
Physicians or members may request an exception to the benefit for reasons of medical necessity. If a formulary alternative is not appropriate or not effective, we will be happy to consider a formulary exception request. Prescribing physicians should have a drug prior authorization form that can be mailed or faxed. The Member Exception Form is available online. If your physician or pharmacist has any questions about the exception process, please ask them to call Customer Care Center. The request is reviewed by the medical director and if approved, the medication is covered at the same level as a formulary drug.

Where do I get help if I have any questions?
Any questions regarding the drug formulary or the exception process should be directed to Customer Care Center by calling 877.230.7555.

Grievance & Appeals Process

We know that at times you may have questions and concerns about benefits, claims or services you have received from Prevea360 Health Plan. Sharing your concerns will help us to identify areas of improvement or clarification needed in our processes or documents as well as help clear up areas of confusion with your benefits or coverage.

When a question or concern arises, we encourage you to reach out to our Customer Care Center at 877. 230.7555. Our Customer Care Specialists will make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care.

If after contacting us, you continue to feel a decision has adversely affected your coverage, benefits or relationship with Prevea360 Health Plan, you may file a grievance (sometimes called an appeal).

Upon receipt of the grievance, the Grievance and Appeals Department will acknowledge your grievance within five business days. Our acknowledgment letter will advise you of your right to submit written comments, documents or other information regarding your grievance; to be assisted or represented by another person of your choice; to appear before the Grievance Committee; and the date and time of the next scheduled meeting, which will not be less than seven calendar days from the date of your acknowledgment and within 30 calendar days of receiving the grievance. If you choose to appear before the Committee, you must notify us. If you are unable to appear before the Committee, you do have the option of scheduling a conference call. Your grievance will be documented and investigated. All grievances will be resolved within 30 calendar days of receipt. You have the right to request a copy of documents, free of charge, relevant to the outcome of your grievance by sending a written request to the address listed below.

If your grievance is determined to be urgent in nature, you may be entitled to an expedited grievance which will be resolved within 72 hours of the receipt. If your grievance meets criteria for an expedited grievance, meaning your situation is deemed urgent in nature or you are receiving ongoing treatment, you are also eligible for an expedited external review concurrent with the internal expedited review of your grievance.

After the internal grievance process is completed, you may also be entitled to an independent external review (IER) if the outcome of your grievance involves care that has been determined not to meet the policy requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of care or where the requested services are considered experimental or investigational. Pre-existing Condition determinations and Policy Rescissions are also eligible for IER. You must exhaust all appeal/grievance options before requesting an independent external review.

However, if we agree with you that the matter should proceed directly to independent review, or if you need immediate medical treatment and believe that the time period for resolving an internal grievance will cause a delay that could jeopardize your life or health, you may ask to bypass our internal grievance process. In these situations, your request will be processed on an expedited basis.  If you or your authorized representative wish to file a request for an independent review, your request must be submitted in writing to the address listed below and received within four months of the decision date of your grievance. Upon receipt of your request, a URAC accredited IER will be assigned to your case through an unbiased random selection process. The assigned IER will send you a notice of acceptance within one business day of receipt, advising you of the right to submit additional information. The assigned IER will also deliver a notice of the final external review decision in writing to you and Prevea360 Health Plan within 45 calendar days of their receipt of the request. A decision made by an IER is binding for both Prevea360 Health Plan and the member with the exception of pre-existing condition exclusions and the rescission of a policy or certificate. You are not responsible for the costs associated to the IER.

 The Grievance and IER procedures are also described in your Member Certificate. Please refer to this document to determine eligibility for IER rights. You may also contact our Customer Care Center at (877) 230-7555 or refer to our website prevea360.com with any additional questions regarding these processes.

You may initiate the Grievance process by submitting your complaint to us in writing to:

Prevea360 Health Plan
Attention: Grievance and Appeals Department
P.O. Box 56099
Madison, WI 53705

New Technology

Every year Prevea360 Health Plan evaluates new medical technology and reviews existing technology to determine if any changes or updates are needed to guidelines outlining appropriate use to ensure you receive the most current and effective treatment. During this process, Prevea360 reviews requests for ongoing care or treatment recommendations for all Utilization Management (UM) decisions, including medical, behavioral health care, pharmaceuticals and medical devices. Nationally recognized resources are used to determine if the technology offers improved outcomes when compared with established products, procedures and behavioral health technologies. Drugs covered under the Prevea360 pharmacy benefit are also reviewed by a Prevea360 medical director along with pharmacists from Prevea Health and Navitus Health Solutions. Whether a product or process is reviewed before or after implementation, Prevea360 follows the review process set by the National Commission for Quality Assurance (NCQA). Based upon the results of the technology assessment, Prevea360 will draft or revise their medical policies if necessary.

Filing Claims

Time is a valuable commodity for all of us; that is why Prevea360 Health Plan minimizes the amount of paperwork required for our members. In most cases, claims are submitted directly to Prevea360 Health Plan by the providers or clinics. On occasion, it may be necessary for you to submit a claim for reimbursement. When submitting the claim be sure to follow these guidelines:

Send an itemized bill from the provider of service. If services were received outside of the United States, you will need to submit the original bill along with an itemized bill that has been translated into English and indicate the appropriate currency exchange rate at the time the services were received. Send the bill within 60 days after the services are received to:

Prevea360 Health Plan
Attn: Claims Department
P.O. Box 56099
Madison, WI 53705

If you have another insurance company that is primary payer, you will have to send the Explanation of Benefits (described below) to Prevea360 Health Plan or your health care provider.

Explanation of Benefits (EOB)
Occasionally, you may be responsible for paying a portion of a claim. The most common financial responsibilities of our members involve deductible, co-insurance, copayment amounts or charges from out-of-network providers. You will be notified of financial responsibilities other than fixed dollar amounts with a form called an "Explanation of Benefits".

The EOB contains important information including the total amount charged, the amount paid by Prevea360 Health Plan, and the amount that is the member's responsibility.

An EOB is not a bill. The dollar amount indicated as member responsibility on your EOB should always be paid to the provider of service upon receipt of a bill, and not to Prevea360 Health Plan.