2024 Prevea360 Large Group Plan Book_SG_SP

2024 Group Insurance Plan Book Choose Prevea360 Health Plan for your health journey

Contents

House calls with Pivotal Health

Discover an unparalleled

health plan experience Health insurance designed around you

Take advantage of your pharmacy benefits

First impressions matter

Take control of your health

About your coverage: Health insurance 101

We make change easy

Terms and Coverage Details

Know the right care for your needs

Policy statements

Have questions? We can help.

Contact Member Services for questions about your benefits and more. 1 (877) 230-7555 (TTY: 711 ) Monday – Thursday, 7:30 am – 5 pm Friday, 8 am – 4:30 pm

CALL

Visit Prevea360.com/ContactUs and select “Send a message to Prevea360”

CLICK

Discover an unparalleled health plan experience

We believe in providing benefits and options that go above and beyond expectations

COORDINATED CARE NETWORK

PHARMACY BENEFIT MANAGER

PROVIDERS

HEALTH PLAN

HOSPITALS

You deserve the best We are a health plan that focuses on your needs, in your community, to meet you where you are.

Coordinated, physician-led coverage and care Our integrated approach focuses on the doctor-patient relationship. That means health providers, a pharmacy team and pharmacy benefit manager, and a health plan all collaborating on a single plan revolving around your health and wellness.

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Health insurance designed around you

Needing care is never convenient, finding the right care should be

Plenty of provider options Prevea360 Health Plan offers a comprehensive network of hospitals, physicians and specialists throughout northeastern and western Wisconsin. Our HMO service area includes these northeastern counties: Brown, Calumet, Door, Kewaunee, Manitowoc, Marinette, Menominee, Oconto, Outagamie, Prevea Virtual Care We’re here to help you feel better quickly. With Prevea Virtual Care,* you can get care now, on your schedule, for most common conditions. No appointment needed. Accessible 24/7 for the whole family. Members can reach trusted Prevea Health providers with convenient online access. Visit Prevea360.com/RightCare for more information.

Physicians ready to care for you • 2000+ physicians • 100+ primary care clinic locations • 500+ specialty care clinics Plus, you’re still covered for an emergency anywhere in the Trusted hospitals Prevea360 Health Plan gives you access to high-quality care and an exceptional patient experience at the following HSHS hospitals: • St. Vincent , Green Bay • St. Mary’s , Green Bay • St. Nicholas , Sheboygan • St. Joseph’s Hospital , Chippewa Falls • Sacred Heart Hospital , Eau Claire Plus, additional medical facilities in your network throughout northeastern and western Wisconsin. See the back cover for a list of awards.

Shawano, and Sheboygan. Find a clinic near you at Prevea360.com/Location .

world. Find a provider at Prevea360.com/Doctors .

* Reference your summary of benefits and coverage for specific Virtual Care costs.

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Health care support Prevea Care After Hours ** is available 24/7/365 whenever you have a health question. If you’re not sure you need to see a doctor — or you’re wondering if you have a problem —connect with an experienced registered nurse at 1 (888) 277-3832 (TTY: 711 ) or 1 (920) 496-4700 . Learn more at Prevea360.com/CareAfterHours . Undergoing treatment? Our Care Managers can answer questions about health care services and provide the support you need if you’re currently undergoing treatment — whether it’s complex care, chronic conditions, mental health or pregnancy — as you transition care to Prevea360 Health Plan. Assistance is also available to move prescription medications from your previous health plan to your Prevea360 Health Plan. Learn more at Prevea360.com/CareManagement .

Out-of-area dependents ‡ Your kids may be out of sight, but they are never out of mind. Prevea360 has coverage for your dependents (until they turn age 26) who are living in another community, away at college, out on a backpacking adventure, or giving adulting a try out of state. Need coverage for your kids? Learn more and complete the form at Prevea360.com/OutOfArea . Prior authorization There are certain medical services or provider visits that must be authorized by Prevea360 Health Plan before we can provide a claims payment. A good rule to remember is that any time you seek services with an out-of-network provider, you will need to get prior authorization.† We require these authorizations so our Medical Affairs team can make sure you are getting the appropriate care. Visit Prevea360.com/PriorAuthorization to learn more.

** Prevea Care After Hours is only available to residents of Wisconsin due to licensing regulations.

† HMO members will need to get prior authorization any time they seek services with an out-of-network provider. PPO and POS members only: If prior authorization or pre-certification is not obtained when required, a penalty may be applied if your service is determined medically necessary. If your service is determined to have been not medically necessary, your claim may be denied. ‡ Out-of-area dependent coverage for non-urgent and non-emergency care applies to large group employer (51+ employees) plans only; please check with your employer’s benefits administrator if you have questions.

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Take control of your health

Stress, anxiety, and chronic conditions can happen to anyone at any time in their lives. Whatever you’re experiencing, you’re not alone.

Health and wellbeing services Since each person is on a different journey to wellness, tailored programs are the best solution to fit your specific needs. A Prevea health and wellness specialist is committed to helping you adopt a healthy lifestyle that supports your wellness goals and achieves long-term success. Health & Wellness Specialist* dedicated to you: • Trained wellness professional that collaborates to identify SMART goals, determine health or lifestyle changes, and establish a plan to achieve maximum results. • An active member of your wellness committee. They attend meetings and help support the creation of action plans for health improvement and staff engagement, that aligns with your mission and goals**. • Provide personal wellness counseling and Whole Person Care services that can help achieve short-term and long-term wellness goals for optimal health and happiness. • Support members through the many variables they face while balancing work, life, and health.

WellSaid tm health education talks Quarterly lunch-n-learn sessions offered virtually, or onsite, led by local Prevea Health experts, scheduled at your convenience and personalized to address members’ health questions and needs. Annual wellness challenge Prevea offers a wide variety of creative wellness challenges for members. They can participate as individuals or as a team. Prevea provides the self-implementation tools and personal support needed to be successful.

* Health and Wellness Specialist services are only available for large group employers. ** G oals can include but are not limited to; chronic disease management such as pre-diabetes and high cholesterol, fitness, nicotine cessation, nutrition, stress management, and weight loss.

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Prevea360.com/Wellness For more information visit:

Extras for your well-being

Resources and rewards to help you achieve your health and wellness goals.

WebMD’s health assessment Based on your individual questionnaire results,

WebMD Living Healthy Portal Find the tools you need to achieve your wellness goals. Through our partnership with WebMD One, you can create a customized health experience for your personal health journey with thousands of resources like monthly interactive wellness challenges, wellness and exercise videos, mental health podcasts, and

WebMD provides health recommendations and a variety of interactive, self-management tools are customized to your health and wellness needs. Start today at Prevea360.com/LivingHealthy . Mental health Stress, anxiety, and depression can happen to anyone at any time in their lives. No one is exempt. Know that whatever stage of life and whatever stress you’re experiencing, you’re not alone. Focused on a holistic approach to your well-being, Prevea360 Health Plan meets you where you are and provides the benefits and support you need. Visit Prevea360.com/MentalHealth to access our resources. Advance care planning One of the most challenging situations is to make health care decisions for people who can’t make decisions for themselves. An advance care plan empowers you to take control of your health care decisions, ensuring your wishes about medical treatment are known. Give yourself and your loved ones peace of mind. We can help you start today at Prevea360.com/Acp .

nutritional resources. Start now at Prevea360.com/LivingHealthy . Scan the QR code to download the “Wellness At Your Side” app for Living Healthy on the go.

Living Healthy rewards Prevention or early detection of common diseases is the best way to be the healthiest you and earn up to $150 in rewards! * There are many common preventive and screening services proven to improve health and it is important to check with your primary care provider to determine which tests are appropriate for you, based on your medical history and family history. Earn points and money for taking care of you! Visit Prevea360.com/LivingHealthy to access your resources and start your Health Assessment today!

Wellness resources We offer many programs and tools that focus on making healthy living achievable and fun. Check our wellness events calendar for live events, download a wellness care package, and watch wellness videos on-demand just by going to Prevea360.com/Wellness .

* Only Prevea360 Health Plan members age 18 and older are eligible for Living Healthy rewards. Check with your plan administrator for reward offerings specific to your plan. Covered adult children (ages 18 and older) can earn up to $100 per year. Visit Prevea360.com/LivingHealthy for full details.

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We make change easy

We help with everything from transferring medical records to selecting a new primary care provider. Providing you with a smooth and easy transition is our top priority.

A patient advocate at your side* Our local Patient Advocates and care team help you navigate through your health care journey with connection, support and education. They ease your transition into the Prevea Health system by transferring medical records, helping set up your MyPrevea account, aligning you with providers or establishing a primary care provider, and scheduling appointments to close gaps in care. To connect with your Patient Advocate, call 1 (920) 272-3550 (TTY: 711 ) or 1 (920) 272-3540 (TTY: 711 ), or email: PatientAdvocate@Prevea.com .

* ASO, ETF, and Federal employees should contact Member Services at 1 (877) 230-7555 (TTY: 711 ) for member onboarding assistance.

Member account Visit Prevea360.com/Login and use your member number located on your ID card to activate your account. • View insurance plan details • Request member ID cards or download a digital copy • Change your primary care clinic • Review past claim details and more

MyPrevea MyPrevea.com allows you to send secure messages to your physician’s office and to view your health records from the comfort of your home and with your mobile device. When you create your Member Profile, you’ll have access to your insurance claims, cost estimates, and documentation anytime. Learn more at MyPrevea.com .

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Not sure of the type of care you need?

Know the right care for your needs Knowing your options for care before you need it is good for your health — and can save you money. We offer a variety of care options that fit your needs and schedule.

Call 1 (888) 277-3832 (TTY: 711 ) anytime to speak with a registered nurse, they are ready to help 24/7/365.

For Virtual Care options, visit Prevea360.com/RightCare .

The Right Care for Your Needs Knowing your care options before you need them saves you time and money

Virtual Care

Primary Care

Urgent Care

Emergency Care

$$$

Life-threatening illness or injury? Go to the nearest emergency room or call 911. Heart attack, stroke, head injury, severe pain.

Primary care clinic full or closed? Visit your nearest Urgent Care facility. When your normal clinic is full or closed and you need immediate care for a cold, flu, rashes, or sprains.

Too sick or unable to drive to the doctor? Fill out an online questionnaire, receive a written diagnosis, treatment, and a prescription. Cold/flu, allergies, lice, etc.

Wish to see your provider for care? Schedule an appointment at your primary care clinic. Same-day appointments are usually available. In-person treatments and annual checkups.

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1 (888) 688-4746 (TTY: 711 ) Schedule through the app or call:

House calls with Pivotal Health

Schedule house calls at home, the office or any other convenient place, and a Pivotal Health provider will come to you.

Health care straight to your door* Make an appointment through Pivotal Health’s innovative mobile app available for iOS and Android. The app allows patients to easily schedule appointments, manage billing and insurance, and access after-visit summaries. You can be seen for: • In-person assessments

• Flu, strep, and RSV • Blood draws for labs

• IV hydration and IV meds • Wound care and stitches • Vaccines and injections

• X-rays and ultrasounds • Medication management Schedule through the app, or call 1 (888) 688-4746 (TTY: 711 ) Monday - Friday, 8 a.m. - 8 p.m., and Saturday and Sunday, 10 a.m. - 7 p.m.

* Service only available for members in the northeastern Wisconsin service area.

GET IT ON

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Prevea360.com/PharmacyBenefits For more information visit:

Take advantage of your pharmacy benefits We have created a package of pharmacy benefits that provides convenience and increases access to more medications at lower costs.

$6 for 6-month supply Our $6 for a 6-month supply program helps members with conditions like diabetes, high blood pressure, mood disorders, and bone health get a 6-month supply of certain generic medications for $6 when they use Costco (retail — Costco membership not needed). See the list of medications at Prevea360.com/PharmacySavings . answers you need to feel confident using your pharmacy benefits to their fullest. A better pharmacy experience starts at Prevea360.com/PharmacyBenefits . Pharmacy Concierge Services Understanding what medications are covered, formularies or when you need a prior authorization feels overwhelming without expert help. Like asking a hotel concierge what are the best places to explore, our pharmacy concierge helps you navigate your benefits, helps onboard new members, and tackles more complex pharmacy-related needs. Find the

90-day Generic maintenance drug program† By providing 90-day supplies of maintenance drugs, you’re spending less and getting more of the medication you need. Member cost share for 90-day fills*: • 2 times your copay for all tier 1 and tier 2 medications through our mail-order pharmacy • 2.5 times your copay for tier 1 and tier 2 generic maintenance medications at retail pharmacies • Tier 3 at 3 times your copay (both mail-order and retail) • Tier 4 is not eligible for a 90-day supply Generic medications Generic medications have the same active ingredients as brand-name medications. They are safe and effective but are far less expensive. Your pharmacist can find available manufacturer coupon programs for high-cost specialty drugs or your doctor may be able to recommend a generic at a lower cost.

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Preventive drug list† Now more medications are covered at $0 for large group members which helps you manage drug costs. New drugs added to the Preventive Drug List include: • Preferred mental health medications • Preferred brand diabetes medications • Preferred Insulin • Preferred inhalers and nebulizer solutions To see the most up-to-date list of $0 preventive drugs, visit Prevea360.com/PharmacyBenefits or review the Member Document Center on Prevea360.com . $0 Preferred diabetic supplies ** Cost should not be a barrier to controlling your diabetes. That’s why all formularies include preferred diabetic supplies such as syringes, lancets, and pen needles at $0 for large and small group members. This way you can focus on staying healthy, not the cost of getting there.

$35 cost-sharing cap on preferred insulin††

Lower costs on the diabetic medication you need. Access your formulary for the most up-to-date listing of insulins.

† B enefits are available only for large group (51+ employees) plans. †† B enefit available for ACA-compliant small group plans. All ACA-compliant small group members, including High Deductible Health Plans (HDHP), will not pay more than $35 a month for preferred insulin. * Members with tier 1 or tier 2 pharmacy benefits with coinsurance will still be charged the full coinsurance amount. ** B enefit is available for both large group (51+ employees) plans and ACA-compliant small group (2 - 50 employees) plans.

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Prevea360.com/NewMember For more information visit:

First impressions matter

Switching insurance and providers can be overwhelming. For a seamless transition, here’s what you can expect from us.

What to expect:

Learn about your benefits

Complete and submit your enrollment application

We mail your new Member ID cards

We mail your Member Guide

Your plan is activated

Patient Care Advocate Local resources that understand the health care system and understand your journey. Our patient care advocates and care team helps ease the move — from transferring medical records and setting up MyPrevea to closing gaps in care. To connect with your Patient Advocate, call 1 (920) 272-3550 (TTY: 711 ) or 1 (920) 272-3540 (TTY: 711 ), or email: PatientAdvocate@Prevea.com . New Member Guide We mail you a New Member Guide at enrollment, which introduces you to your new plan and health partner, Prevea360 Health Plan. Your guide will: • Provide details like where to find important member documents • Explain where to go for primary, urgent and emergency care • Define common insurance terms and more

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Health insurance documents 101: The following four member documents are important. They include:

Your Member Certificate This is detailed information explaining how your plan works and what medical benefits you have. You’ll find information like patient rights, benefit limitations and exclusions, cost-sharing requirements, and prior authorization requirements 3 Summary of Employer-Specific Coverage This summary is specific to your company’s coverage information, and it is included with this packet. You can also ask your plan administrator

Summary of Benefits and Coverage (SBC) An SBC is a snapshot of Prevea360 Health Plan’s costs, benefits, covered health care services, and other features. It also explains our unique features like cost-sharing rules and includes significant limits and exceptions to coverage in easy-to-understand terms.

4 Schedule of Benefits

This document lists the services and treatments

covered by your health plan and their associated fees. It is important to read the schedule of benefits carefully and contact customer care if anything is unclear.

or benefits specialist for your specific benefits and coverage information.

15 Visit Prevea360.com or call 1 (877) 230-7555 (TTY: 711 ) |

Call our Customer Care Center at 1 (877) 230-7555 (TTY: 711 ) Questions about health care services?

About your coverage: Health insurance 101

Our goal is to help you understand your health insurance, coverage, and financial responsibilities.

Sharing the cost of care Your policy may use a system of cost sharing that can include a copay, coinsurance, deductible or any combination of the three.*

1 Deductible

Each time you receive medical services, you’ll pay the bill toward these services up to a certain amount. This amount is your deductible, which is what you must pay for covered health care services each year before we begin to pay. Coinsurance † Once you’ve paid the deductible amount, your insurance will then start splitting the cost of additional medical services with you. This is known as coinsurance, where you only pay a percentage or part of the total cost of services and we’ll pay the rest. Deductible and coinsurance limit There is a dollar limit to the amount you’ll pay toward your deductible and coinsurance. Copays A copay is a fixed dollar amount, which you pay at the time you receive medical services (for things like an office visit) and prescriptions. All your copays add up toward your Maximum Out-of-Pocket total. Maximum out-of-pocket There’s a dollar limit to all your cost sharing. You reach this amount by means of your deductible, plus your coinsurance, plus your copays. Once this limit is reached, you’ll pay nothing on subsequent covered medical charges for the remainder of your policy year.

* Not all of the cost-sharing terms listed here apply to all members. Refer to your Member Certificate to understand which apply to you. Smart Plan medical copayment applies towards the maximum out-of-pocket, which is the amount you are required to pay toward the covered cost of your healthcare. The out-of-pocket maximum amount is calculated on a contract year or calendar year basis. For members with PPO and POS Smart Plans, coinsurance and copays apply. † Coinsurance is your share of the costs of a covered health care service. It’s calculated as a percent of the allowed amount for the service.

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Essential health benefits Defined as the 10 categories of common benefits that are deemed essential,** these Essential Health Benefits can’t be subject to dollar limits, either annually or on a lifetime basis. Depending on the type of plan you purchased, services associated with Essential Health Benefits may still require cost sharing in the form of copays, coinsurance, and deductibles. These include: • Preventive*, wellness, and disease management services • Emergency care • Hospitalization • Ambulatory care • Maternity and newborn services • Prescription drug coverage • Pediatric services† • Laboratory services • Rehabilitative and habilitative services

Preventive services At the heart of our preventive care is a holistic care philosophy that you’ll get the support needed to remain healthy and enjoy life. We provide the following preventive services with no copays, coinsurance, or deductibles:* • Annual Preventive Office Visit, which includes important preventive services • Screenings for breast, cervical, and colon cancer • Cholesterol screenings • Routine vaccinations for adults and children • And more services Visit Prevea360.com/PreventiveCare or call the customer care center at 1 (877) 230-7555 (TTY: 711 ) for a comprehensive list of covered preventive services.

Review our glossary of common terms at Prevea360.com/InsuranceTerms

• Mental health and substance use services, including mental health treatment

* No cost share responsibilities apply when services are delivered by a network provider, and when all preventive services criteria are met. Visit Prevea360.com/PreventiveCare for a comprehensive list of covered preventive services. ** A ll small group plans (2–50 employees) cover Essential Health Benefits. However, if you work for a larger employer (51+ employees) your benefits may vary. Contact your human resources, benefits administrator, or benefits department for information about your specific coverage. † Prevea360 Health Plan does not offer pediatric dental services. This coverage is available on the Health Insurance Marketplace ( Healthcare.gov ) and can be purchased as a stand-alone product. Please contact your benefits administrator or the Marketplace to purchase pediatric dental coverage or a stand-alone dental services product.

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Policy statements

Protecting your health information

Health equity statement Prevea360 Health Plan is committed to health equity, which holds that no person be disadvantaged from achieving their potential as a result of barriers. We consider the many characteristics that make people unique — such as race, ethnicity, gender, sexual orientation, abilities, age, socioeconomic status, or veteran status — because any of these differences may be the basis for disparities in health care access, experience and outcomes. The workgroup is made up of people from across, and at all levels, of the company. The principles and commitments that guide our health equity work align with four areas of focus: • Leadership and decision-making: We will seek diversity in our representation and engagement to guide our work and decision-making at all levels of Medica, including our workgroup and leadership activities, and in our decision-making, policy and program development. • Data practices: We will expand our data collection efforts, where appropriate, to guide necessary health equity interventions and evaluate our health disparities reduction efforts. • Policies and procedures: We will examine our policies using an equity lens and make policy changes needed to promote equity, reduce health disparities, and eliminate barriers or unintended impacts on historically underrepresented and/or marginalized groups. • Access and outcomes: We will review and develop policies and care models that improve access to care and community resources that meet our members’ diverse health-related social needs and preferences.

Privacy and confidentiality statement Prevea360 Health Plan is required by law to maintain the privacy of your personal health and financial information (collectively referred to as “nonpublic personal information”) and provide you with written notification of our legal duties and privacy practices concerning that information. Please visit Prevea360.com/Privacy or call 1 (877) 230-7555 (TTY: 711 ) to request a copy. Prior authorization There are certain medical services or provider visits that must be authorized by Prevea360 Health Plan before we can provide a claims payment. A good rule to remember is that any time you seek services with an out-of-network provider, you will need to get prior authorization.* We require these authorizations so our Medical Affairs team can make sure you are getting the appropriate care. Visit Prevea360.com/ PriorAuthorization to learn more. General limitations and exclusions All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your member certificate. The following list is not exhaustive and may vary based on your policy. For a complete listing refer to your member certificate.

* HMO members will need to get prior authorization any time they seek services with an out-of-network provider. PPO and POS members only: If prior authorization or pre-certification is not obtained when required, a penalty may be applied if your service is determined medically necessary. If your service is determined to have been not medically necessary, your claim may be denied.

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Have questions? We can help.

Hospital and Health System Awards HSHS St. Mary’s Hospital Medical Center: • Named a Top 100 hospital in the nation designated Baby-Friendly birth facility • Guardian of Excellence Award® for achieving and sustaining excellence in clinical quality – Press Ganey • Accredited by the Joint Commission of Accreditation of Healthcare Organizations • Partner for Change Award – Practice Greenhealth • Greening of the OR Award – Practice Greenhealth HSHS St. Vincent Hospital: • Accredited by the Joint Commission of Accreditation of Healthcare Organizations • Green Bay’s first and only dedicated children’s hospital and a Level II trauma center • Certified Comprehensive Stroke Center • Greenhealth Emerald Award – Practice Greenhealth • Greening of the OR Award – Practice Greenhealth HSHS St. Vincent Hospital Cancer Centers: • Accredited by the Commission on Cancer for more than 55 years • Recognized as an Integrated Network Cancer Program – highest level of accreditation possible for a non-teaching hospital HSHS St. Clare Memorial Hospital: • Guardian of Excellence Award® for achieving and sustaining excellence in clinical quality – Press Ganey

Call us toll-free at: 1 (877) 230-7555 (TTY: 711 ) Monday - Thursday, 7:30 am- 5 pm Friday, 8 am - 4:30 pm

Prevea360 Health Plan PO Box 56099 Madison WI 53705-9399 Toll-free 1 (877) 230-7555 (TTY: 711 ) Prevea360.com

Prevea360 Health Plan does not discriminate on the basis of disability in the provisions of programs, services, or activities. If you need this printed material interpreted or in an alternate format, or need assistance in using any of our services, please contact a Customer Care Specialist at 1 (877) 230-7555 (TTY: 711 ).

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