Your coverage Making changes to your plan
Member rights & responsibilities You deserve the best service and health care possible. Rights and responsibilities help foster cooperation among members, providers and Prevea360 Health Plan. Visit Prevea360.com/Legal/Member-Rights-and- Responsibilities to view all of your member rights and responsibilities. Grievance & external independent review rights We know that at times you may have questions and concerns about benefits, claims or services you’ve received from Prevea360 Health Plan. When a question or concern arises, we encourage you to reach out to Member Services. We’ll 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 coverage. 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 or appeal. Visit Prevea360.com/Appeals for details on how to file or for more information about these procedures. You may also find information in your Member Certificate or Summary. Contact the Customer Care Center with any questions about the process. See page 3 for contact details. How to submit a complaint If you have a complaint, please contact Member Services at 877-230-7555 (TTY: 711) . We will document and investigate your complaint and notify you of the outcome. For more information, visit Prevea360.com/Appeals . Terms & conditions All your benefits are subject to terms and conditions as described in your Schedule of Benefits and in your “Member Policy.” Please refer to these important documents for complete details. Drugs and new medical technology Each year, we evaluate new and existing medical technology to determine if any updates to medical policies are needed. Drugs covered under your pharmacy benefit are also reviewed by a Prevea360 Health Plan medical director and pharmacists from SSM Health System and Navitus Health Solutions. Prevea360 Health Plan follows the review process set forth by the National Committee for Quality Assurance (NCQA) any time there is a new product or process. Based upon the results of the technology assessment, Prevea360 Health Plan will revise its medical policies if necessary.
We understand that sometimes big events happen in your life and it means you need to make a change to your coverage with Prevea360 Health Plan. You can make changes to your plan outside of the designated open enrollment period but only if you have a qualifying event that would trigger a special enrollment period.
Let us know if you have other coverage or Medicare Do you have health insurance coverage in addition to your coverage through Prevea360 Health Plan? When you have coverage through more than one source, we have to determine in what order claims will be paid, referred to as coordination of benefits. It is especially important that you notify us when you are eligible for or are enrolled in Medicare. In situations when Medicare is or will be the primary payer, we strongly suggest that you enroll in both Medicare Part A and Part B. † We’re here to help you sort it all out. If you are enrolled in Medicare or have questions about Medicare, please contact the Medicare Coordination of Benefits Specialist at 608-827-4189 (TTY:711) . To report additional coverage other than Medicare, please call Member Services at 877-230-7555 (TTY: 711) . † You are Medicare-eligible if you are a legal U.S. resident and one of the following applies to you: • You are age 65 or older • You are any age and have a qualifying permanent disability • You are any age and have been diagnosed with end-stage renal disease (ESRD)
Visit Prevea360.com to find information on your benefits | 23
22 | 2024 Group Member Guide
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