2023 Prevea360 Health Plan Group Plan Book_SGP

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 877-230-7555 (TTY: 711) to request a copy.

• Services, treatment, and supplies provided in connection with any illness or injury caused by: a Member engaging in an illegal occupation or b) a Member committing or attempting to commit, a felony. (Note that this exclusion does not apply to the treatment of injuries that result from an act of domestic violence, if that treatment would otherwise be covered). • Services provided by Members of the subscriber’s immediate family or any person living with the subscriber • Services or supplies associated to a denied prior authorization • Services or supplies associated to a denied admission • Services or supplies not medically necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license • Services or items provided as a result of war or any act of war, insurrection, riot or terrorism • Services or supplies provided for an injury sustained while performing military service • Services or supplies for which a Member receives or is entitled to receive any benefits, settlement, award, or damages, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance plan, or similar law or act. “Entitled” means the Member is actually insured under Workers’ Compensation. • Surrogacy services, for a non-Member • Sexual dysfunction treatment and services including, but not limited to surgery • Sterilization procedures for men • Sterilization procedures for women and patient education and counseling related to contraception for all women with reproductive capacity. (Although these are technically excluded from your group’s health plan insurance coverage, we will pay for them as preventive services, as required by federal regulations)

• Take home drugs and supplies unless a written prescription is obtained and filled at a network pharmacy • Acupuncture • Chelation therapy for atherosclerosis • Coma stimulation programs • Alternative medicine, not otherwise listed in the policy • Low level light therapy • Massage therapy • Prolotherapy • Swim or pool therapy, unless prior authorization is obtained • Administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics • Court-ordered care, unless medically necessary and otherwise covered under this certificate • Educational services, except for diabetic self- management classes • Internet consultations, including all related charges and costs, excepts as defined by our medical policy • Missed appointment charges • Telephone consultation charges between providers • Charges or costs exceeding a benefit maximum or maximum allowable fee, where applicable • Expenses incurred before the supply or service is actually provided unless prior authorized by us This notice was last updated August 15, 2022.

Visit prevea360.com or call 877-230-7555 |

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