WHAT'S INSIDE
`
`Welcome to Meclica
`
`Page 2
`
`=eatur es of Medica Elect "1"
`and Medica Essential” Plans
`
`°age3
`
`Questions & Answers
`
`3age 4
`
`Choosing a
`3rin1ar 3,! Car e Doctor
`3age 5
`
`‘vieclica CallLink "'”:
`2dl»hour Nurse |Jne Answers
`Your Health Questions
`
`5age5
`
`Our Goal is to Help Our
`Vlembers Stay Healthy
`Page 6 & 7
`
`-low to Enr oll
`
`

`
`WE LCOME TO MEDI CA
`
`At Medica, we serve members and employers by offering a br oad range of health plans with
`
`many soug ht-after featur es, including:
`
`- choice in selecting doctors and other health car e providers,
`
`- exceptional customer service,
`
`- easy access to health car e,
`
`- a quality—first, member —first focus,
`
`- innovative pr eventive car e pr ogra ms, and mor e.
`
`No wonder our members consistently give us high marks in satisiaction. But we ar e mor e than just an
`organization that oi iers a variety oi health plans.
`
`We pr ovide access to caring and dedicated health car e proiessionals — including the primary car e doctors
`who make sur e you and your iamily ar e up to date on all oi your immunizations, mammograms, aller W
`shots and other pr eventive car e checl<—ups.
`
`Register ed nurses ar e available 24 hours a day via Medica CallLin k"? The nurses can help you decide in the
`middle oi the night whether you should take your ieverish, coughing child to the emer gency room or tr eat
`your child at home. They can answer many other health-r elated questions and provide r eierrals to doctors,
`clinics and hospitals.
`
`Medica Customer Service r epr esentatives ar e available by phone during r egular business hours. They can
`answer your questions about a claim or coverage, or give you advice on how to get a pr escription r efilled
`when your e out oi town.
`
`.medica.com to
`Medica'sW eb site also brings you health car e inlormation 24 hours a day . Log on to '.-‘.I".-‘.a".-‘.-'
`locate inlormation about medical conditions or tests, sear ch provider directories, r ead thr ough Medica's
`drug iormulary (list oi pr eierr ed drugs] or send a message to Customer Service.
`
`We know you want the ver y best health car e for yourself and your family . At Medica, we'll do our best
`to make sur e you r eceive high—quality car e — and that you have all the inlormation and support you need
`to make wise decisions ior you and your lamily W e know that being a wise health car e consumer includes
`understanding your health plan. W ith that in mind, we've developed this material
`to introduce you to
`Medica Elect"’ and Medica Essential care system plans.
`
`Welcome to the family . Medica is a iamily oi non-pr ofit and ior—proiit businesses: Medica Health Plans,
`Medica Health Plans oiW isconsin, Medica Insurance Company (MIC), Medica Sell-Insured (MSIJ, Medica
`Holding Company and Medica Foundation. Medica Elect and Medica Essential are available through
`Medica Health Plans, MIC and MSI in ar eas with established car e systems.
`
`We are pleased to be able to serve you and one million other members with br oad access to quality car e
`and a host oi value—added services. Once again, welcome to Medica.
`
`

`
`FEATURES OF MEDICA EL ECT®
`
`AND MEDICA ESSENTIAL 5'“
`
`CARE SYSTEM PLANS
`
`With iviedica Elect“ and Medica Essential“ plans, you
`
`select a primary car e clinic that is part of a compr ehensiye
`
`care system of primary care and specialty car e providers,
`
`hospitals and other health pr oiessionals. Y our primary care
`
`clinic coor dinates all of your health car e services.
`
`FEATURES OF
`ALL MEDI CA ELECT*’ AND MEDICA ESSENTIAL 9"‘
`PLANS INCLUDE:
`
`No claim for ms to ‘file, no bills to or ganize. Simply
`show your Medica ID car d at your Medica
`Elect"’ or Medica Essential nelwo-rl< clinic each
`
`time you r eceive care and we'll handle the r est.
`
`Preventive check-ups ar e cover ed. At Medica,
`keeping you heal thy is our primary goal. W e covera
`wide range oi pr eventive car e services, when car e
`is directed by your primary car e clinic or physician.
`Check your Summary oi Beneiits ior a list oi
`these services.
`
`Prescription costs ar e cover ed. When you iill orr efill
`a pr escription at a Medica networl< pharmacy ,you
`areresponsible only ior Ihe "copay" — the member‘s
`contribution toward the total costoi the drug. The
`rest oi the cost is cover ed. Several national drugstor e
`chains ar e network pharmacies, so you can be assured
`oi getting coverage ior pr escription r eiills even when
`your e away ir om home. For convenience, members
`can choose to use a mail-or der pharmacy program.
`This service is especially useiul
`to members with
`long—term health conditions who need the same
`medicine on an ongoing basis.
`
`Emer gency medical costs ar e cover ed —no matter
`where you travel. When you receive emergency
`medical services ir om a networl< ur gent car e center
`or emergency r oom, your e cover ed. Y ou‘r e also
`covered ior emergency car e r eceived ir om non-
`network providers or hospitals anywhere in the
`world. Just carry your Medica ID car d wilh you and
`travel with coniidence.
`
`Great customer ser vice. No matter which plan you
`choose, you'll
`iind that whenever you have a
`question — whether it‘s about beneiits, service or
`any other aspect oi your health car e coverage —
`you'll get pr ompt, helpiul and courteous answers
`irom Customer Service. We are very proud that our
`customer satislaction rates ar e consistently high.
`
`Our commitment to quality r ecognized. Medica
`has r eceived "excellent" accreditation status ir om lhe
`
`Nalional Committee ior Quality Assurance (NCO A"’],
`the nation's leading sour ce ior evaluating the quality
`oi managed car e plans. Medica's excellent status is
`the NCQA ‘s highest rating.
`It means that Medica
`meets strict NCQA standar ds and has exceptional
`programs ior continuous quality impr ovement
`
`

`
`QUESTIONS 8: ANSWERS
`
`ABOUT MEDI CA EL EC|'® AND
`
`MEDICA ESSENTIA L“ PLANS
`
`Do I have to select a primar ycar e doctor
`or clinic when I enr ol?
`
`Yes.Y ou and any cover ed lamily members do need
`to choose a primary car e clinic. Family members can
`choose dil ler ent clinics, and you may change clinics
`within your care system plan during the course ol
`the year. Customer Service can pr ovide you with the
`requirements and pr ocedures lor changing clinics il
`you wish to do so.
`
`Do I need to call Medica befor er eceiving ser vices?
`Generally, no. However,
`to assure that you receive
`appropriate care, a limited number ol services, pr escn'p tion
`medications and medical supplies require that you obtain author-
`i.:ation belore receiving them. For a complete list you may call Medica‘s
`Customer Service.
`
`Do I need a r efer ralfr om my primar ycar e clinic or doctor to see a specialist in my network?
`Your primary car e clinic coor dinates all ol your health car e services. In most cases, to r eceive the highest
`level ol coverage, you will need to be r elerr ed by your clinic or doctor to a specialist.
`
`However, there are some exceptions. Y ou have dir ect access to the lollowing within your Medica Elect '”
`or Medica Essential
`network:
`
`- Urgent care centers
`- OB4/GYN doctors
`
`I Mental health/substance abuse pr oviders
`- Optometrists or ophthalmologists once a year lor a routine, pr eventive eye exam.
`
`Can I see non-network pr oviders?
`You ar e covered lor emergency car e pr ovided by non-networl< doctors or hospitals anywhere in the world.
`llyour doctor relers you to a specialist who is not in the Medica Elect"’ plan or Medica Essential plan
`network, contact Customer Service prior to seeing the specialist to learn how your car e will be cover ed.
`
`Check the Summar y of Benefits for each Medica Elect“ plan or Medica Essential” plan to get
`additional infor mation on cover ed services and applicable copays.
`
`

`
`CHOOSI NG A PRIMARY CARE DOCTOR
`
`Medica encourages you to develop a long—terrn r elationship with one doctor
`
`forr outine car e. That doctor will become familiar with your health, family
`
`and treatment history , which is very helpful when pr oviding car e. And you
`
`will likely feel mor e comfortable seeing the same doctor over time,
`
`instead
`
`of having a new doctor at each visit.
`
`Here ar e the thr ee most common types
`of primary care doctors:
`
`Family practice doctors. These doctors specialize
`in taking car e ol the general health needs ol people
`olall ages, lr om inlancy thr ough adulthood. They ar e
`trained in six br oad ar eas ol medicine: pediatrics,
`internal medicine, sur gery, obstetrics and gynecology ,
`psychiatry and community medicine.
`
`Inter nists. These doctors specialize in the diagnosis
`and tr eatment ol diseases in adults. They do not
`perlorm surgery, deliver babies or tr eat childr en.
`
`Pediatricians. These doctors specialize in taking
`car e ol the general health needs ol children, lron
`birth thr ough about age ‘lb.
`
`In addition, you have dir ect access to obstetrician-
`gynecologists within your car e system. These
`doctors specialize in pr egnancy and childbirth, and
`in the diseases and r outine physical car e related to
`a woman’ s reproductive system.
`
`Some 'l:hings to consider when choosing
`a primar y care doctor:
`
`The doctor '5 training and experience. You wantto
`be com lortable that your doctor has the kind ol
`training and experience that is right lor you. Ask
`about his or her experience with ar eas olmedicine
`thatmay be ol special concern to you or your lamily.
`
`The doctor ‘s accessibility . You wantyour doctor to be
`available when needed. Find out the ol lice hours and
`
`how long it takes to schedule a r outine visit. Ask who
`covers lor the doctor when he or she is out ol town.
`
`The doctor ‘s appr oach to pr eventive medicine.
`You want a doctor who emphasizes staying healthy .
`Note whether the doctor asks you about your lood
`choices, exer cise habits, smoking and alcohol
`
`intake, as well as about any health
`risks you may be exposed to on
`the job or at home. Does the
`doctor r ecommend preventive
`care services such as r outine
`
`physicals, immunizations and mammograms? Does
`the doctor answer your questions about how you
`can make healthy impr ovements in your lilestyle?
`
`ll you want help in choosing a primary car e doctor,
`call Medica Calltink {Medic a‘s nurse line. A r elerral
`specialist will help you lind the doctor who best
`meets your needs.
`
`MEDI CA CallLink *’
`24-hour Nurse Line
`Answers You Health Questions.
`
`One ol Medica‘s most popular leatur es is our nurse
`line, Medica CallLink "’. This 24—hours—a—day , 3o5clays—
`a-year service is stalled by registered nurses who are
`ready to answer your questions on a variety ol medical
`topics and situations.
`Medica Calltink "‘ nurses answer thousands ol calls
`
`each year lr om Medica members.They give advice
`on a wide range ol concerns, lr om how to find a
`heal thr elated support gr oup to how to tr eat a minor
`burn or remedy a child's slully nose.
`
`lind that quick, sound
`With Medica C.al|Link '”, you'll
`medical guidance is only a phone call away.
`Medica CallLink *3:
`1-BOD-962-9497
`
`Hearing-impair e:l {TTY) callers:
`952-992-2357
`or1 -300-23:1» E319
`
`

`
`OUR GOAL IS TO HE LP OUR MEMBERS STAY HEALTHY
`
`At lvledica, our goal is helping you stay healthy .T o that end, we offer members a wide
`
`variety of health education information as well as personalized assistance for members with
`
`certain chr onic diseases. W e encourage you to become an informed consumer of health car e
`
`services and to take full advantage of cover ed prevcntivc car e services.
`
`HEALTH EDU CATION INFOR MATION
`
`l‘.r'iu;'clr'ct'i Horiltl: Huiaclboolc. This awar da.-winning sell-
`car e health manual helps you take a more active r ole
`in your health. It covers common health topics, such
`as allergies, bacl< pain, ear inlections and rashes,
`and many other health conditions and symptoms.
`Under each topic, you'll lind detailed inlormation on
`home tr eatm en ts and pr even tion, as well as in lorm a tion
`about when to call a health car e pr olessional.
`
`Member publication. Hz=..=i-J'rl1y Arrirucles“ . Medica
`members are mailed a quarterly publication called
`Healthy Atfitudefi It contains uselul health educa —
`lion iniorrnation, pr eventive car e r eminders, ben —
`elits iniormation and mor e.
`
`24-hour nurse line. Medica CallLinl< '”
`
`is a nurse
`
`PREVENTIVE CARE
`
`line service available to members 24 hours a day
`by telephone.
`Hea|1:hFor ums Online. Go tow'w'w _medica_com and
`
`click on the link lor HealIhForums to get iniormation
`about minor illnesses and injuries, routine and
`trgent health situations, nutrition, litness and med —
`ications. The site provides access to an easy—to-use
`medical encyclopedia and dictionary , pr escription
`drug inlormation, symptom guide, leatur e articles
`and summaries oi medical journal articles.
`
`Medica strongly believes that appr opriate health
`scr eenings and immunizations ar e vital ways lor you
`to maintain your health.
`
`We work with you and your doctor to inlorrn you
`about r ecommended timelines and ages lor health
`screenings. Likewise, we encourage you to work
`with your doctor to stay curr ent with screenings
`and immunizations.
`
`

`
`CARE MANAGEMENT SER VICES
`
`"Car e management" is a gr oup ol services Medica
`provides to make sur e you obtain appr opriate car e
`and to assist in coor dinating benelits and services.
`Car e management is an important component oi
`promoting wellness and includes the lollowing:
`
`0 Prior authorization ol certain services,
`medications and medical supplies.
`
`- Utilization management.
`
`0 Case management lor individuals with
`complex and catastr ophic health pr oblems.
`
`0 Disease management lor members with
`diabetes, asthma and other chronic illnesses.
`
`- Discharge planning.
`Prior authorization. Prior authorization is a r eview
`oi a limited number ol services, medications or
`medical supplies conducted in advance ol pr oviding
`the service or treatment.
`It
`is intended to deter-
`
`mine their medical necessity‘ — and to make sur e
`that the car erequested is needed and appropriate
`and will be deliver ed in the proper setting lor
`the optimal length ol time. The r eview also ensur es
`that
`the services are covered under your plan
`benelits. You may appeal an authorization decision
`that you or your doctor disagree with. See an
`outline of the appeals process in materials that
`accompany this br ochure or call Customer Service
`lor additional inlormation.
`
`Utilization management. Utilization managementis
`a clinical r eview pr ocess used with a small number ol
`complex medical conditions. The pr ocess checks on
`
`the ongoing medical necessity* and appropriate —
`ness olhealth car e services and treatment plans.
`This review is conducted by a licensed medical
`prolessional as the services ar e being perlormed.
`You may appeal a decision that you or your doctor
`disagrees with. See an outline ol the appeals pr ocess
`in materials that accompany this br ochur e or call
`Customer Service lor additional inlormation.
`
`Case management. Nurse case managers pr ovide
`assistance, education and guidance to members and
`their lamilies who are going thr ough major acute,
`complex and long—term health pr oblems. The nurse
`case manager works closely with members,
`their
`doctors and community r esources to coordinate
`the care being pr ovided.
`
`Disease management. Disease management coor —
`dinates and improves services provided to a
`member lor a given disease or condition, such as
`diabetes or asthma,
`throughout the course ol
`treatment. This includes pr oviding members with
`educational resources to help them understand
`and manage their condition. Disease manage-
`ment encourages pr eventive car e and promotes
`improved member satislaction with the health
`care delivery system.
`
`Dischar ge planning. Discharge planning is the
`evaluation ol a member's medical needs in or der
`
`to arrange appr opriate car e alter the member is
`dischar ged lr om an inpatient setting [hospital or
`long-term-car e lacility].Dischar ge planning pr omotes
`continuity and coor dination ol car e.
`
`* Medical necessity refers to detennining whether hea lth care senrices are medically appropriate and needed to meet
`basic health needs, consistent with the diagnosis or condition, and that they are provided in a cost—eFFer:th.ve manner.
`See your summary of benefits for a more complete explanation ofmedical necessity.
`
`

`
`HOW TO ENROLL
`
`Here are the ‘four simple steps you should take
`to complete your enr ollment.
`
`1. Select the Medica plan that‘ s best for you.
`
`2 If you ar e selecting a Nleclica Elect *3 plan:
`Choose a primar 3' car e clinic fr om the Meclica Elect 9 network for
`each ‘family member . Check the Medica Elect"’ provider dir ectory
`(available online at www .medica.co m ] to see iiyour curr ent primary
`care clinic is listed and to view available options. Call Customer
`Service ii you have any questions.
`
`If you ar e selecting a Meclica Essential "‘ plan:
`Choose a primar ycar e clinic ‘ir om the Nleclica Essential ‘-‘*‘ network
`for each family member . Check the Medica Essential provider
`dir ectory (available online at www .medica.co m ] to see iiyourcurr ent
`pn'mary care clinic is
`listed and to view available options. Call
`Customer Service ii you have any questions.
`
`.
`
`If you ar e selecting a new doctor or clinic. call to make sur e1:he
`doctor or clinic is accepting new patients. Also, r equest a transier
`olyour medical r ecords ir om your previous doctor to your new one.
`(Your pr evious doctor's clinic may char ge you a small lee to cover the
`paperworl< and time involved in the transier.]
`
`Complete all enr ollment materials. Please be sure to include the
`Social Security number on the enr ollment iorm and date oi birth ior
`yoursell and each oi your iamily members desiring coverage. And
`rememberyou need to identily a primary car e clinic lor each enr ollee.
`
`liyou are declining enrollment ior yoursell or your iamily members
`because oi other health insurance coverage, you may, in the iulur e,be
`able to enroll yoursell or your dependents in this plan, provided that
`you request enr ollment within 30 days oi your other coverage ending.
`In addition, ii you have a new dependent as a r esult oi marriage, birth,
`adoption or placement ior adoption, you may be able to enr oll yoursell
`and your dependents, provided that you request enrollment within
`3.) days oi the marriage, birth, adoption or placement ior adoption.
`
`

`
`

`
`

`
`MEDICI9
`m'_».rl".I'1e+:|iI::a.t:::trn
`
`E31952 33999999500
`ELI‘-:1 SL.|E|'-.-1 #4‘. E93
`ID: 499999992
`Mar.-1E[5f.
`|'I.|hi.FITHfi.|"v| LE1I'I’l5
`
`AEDDLJNT: [G-rnu[_'n#] ears:
`C2!-.RE TYPE: MEEIBA ELEC.“T-sample
`S‘-.-‘E T"|"F‘ E: ME EIICTAL
`
`PEP f'~1-'5uJ".-1E:
`
`PEP PH Dl'~lE#'.
`
`[999] 999-9999
`
`E1:pa_.r5;
`
`CH"
`F'I:|I|..B|EF-."
`
`519.99
`$19.99
`
`E
`
`can N_Im|:Er:'EardDah3
`99999999999999'99 J'99.I'99
`
`

`
`

`
`

`
`WHAT'S INSIDE
`
`Welcome to Meclica
`
`Page 2
`
`=eatur es of Medica Elect "1"
`and Medica Essential” Plans
`
`°age3
`
`Questions & Answers
`
`3age 4
`
`Choosing a
`3rin1ar 3,! Car e Doctor
`3age 5
`
`‘vieclica CallLink "'”:
`2dl»hour Nurse |Jne Answers
`Your Health Questions
`
`5age5
`
`Our Goal is to Help Our
`Vlembers Stay Healthy
`Page 6 & 7
`
`-low to Enr oll
`
`

`
`WE LCOME TO MEDI CA
`
`At Medica, we serve members and employers by offering a br oad range of health plans with
`
`many soug ht-after featur es, including:
`
`- choice in selecting doctors and other health car e providers,
`
`- exceptional customer service,
`
`- easy access to health car e,
`
`- a quality—first, member —first focus,
`
`- innovative pr eventive car e pr ogra ms, and mor e.
`
`No wonder our members consistently give us high marks in satisiaction. But we ar e mor e than just an
`organization that oi iers a variety oi health plans.
`
`We pr ovide access to caring and dedicated health car e proiessionals — including the primary car e doctors
`who make sur e you and your iamily ar e up to date on all oi your immunizations, mammograms, aller W
`shots and other pr eventive car e checl<—ups.
`
`Register ed nurses ar e available 24 hours a day via Medica CallLin k"? The nurses can help you decide in the
`middle oi the night whether you should take your ieverish, coughing child to the emer gency room or tr eat
`your child at home. They can answer many other health-r elated questions and provide r eierrals to doctors,
`clinics and hospitals.
`
`Medica Customer Service r epr esentatives ar e available by phone during r egular business hours. They can
`answer your questions about a claim or coverage, or give you advice on how to get a pr escription r efilled
`when your e out oi town.
`
`.medica.com to
`Medica'sW eb site also brings you health car e inlormation 24 hours a day . Log on to '.-‘.I".-‘.a".-‘.-'
`locate inlormation about medical conditions or tests, sear ch provider directories, r ead thr ough Medica's
`drug iormulary (list oi pr eierr ed drugs] or send a message to Customer Service.
`
`We know you want the ver y best health car e for yourself and your family . At Medica, we'll do our best
`to make sur e you r eceive high—quality car e — and that you have all the inlormation and support you need
`to make wise decisions ior you and your lamily W e know that being a wise health car e consumer includes
`understanding your health plan. W ith that in mind, we've developed this material
`to introduce you to
`Medica Elect"’ and Medica Essential care system plans.
`
`Welcome to the family . Medica is a iamily oi non-pr ofit and ior—proiit businesses: Medica Health Plans,
`Medica Health Plans oiW isconsin, Medica Insurance Company (MIC), Medica Sell-Insured (MSIJ, Medica
`Holding Company and Medica Foundation. Medica Elect and Medica Essential are available through
`Medica Health Plans, MIC and MSI in ar eas with established car e systems.
`
`We are pleased to be able to serve you and one million other members with br oad access to quality car e
`and a host oi value—added services. Once again, welcome to Medica.
`
`

`
`FEATURES OF MEDICA EL ECT®
`
`AND MEDICA ESSENTIAL 5'“
`
`CARE SYSTEM PLANS
`
`With iviedica Elect“ and Medica Essential“ plans, you
`
`select a primary car e clinic that is part of a compr ehensiye
`
`care system of primary care and specialty car e providers,
`
`hospitals and other health pr oiessionals. Y our primary care
`
`clinic coor dinates all of your health car e services.
`
`FEATURES OF
`ALL MEDI CA ELECT*’ AND MEDICA ESSENTIAL 9"‘
`PLANS INCLUDE:
`
`No claim for ms to ‘file, no bills to or ganize. Simply
`show your Medica ID car d at your Medica
`Elect"’ or Medica Essential nelwo-rl< clinic each
`
`time you r eceive care and we'll handle the r est.
`
`Preventive check-ups ar e cover ed. At Medica,
`keeping you heal thy is our primary goal. W e covera
`wide range oi pr eventive car e services, when car e
`is directed by your primary car e clinic or physician.
`Check your Summary oi Beneiits ior a list oi
`these services.
`
`Prescription costs ar e cover ed. When you iill orr efill
`a pr escription at a Medica networl< pharmacy ,you
`areresponsible only ior Ihe "copay" — the member‘s
`contribution toward the total costoi the drug. The
`rest oi the cost is cover ed. Several national drugstor e
`chains ar e network pharmacies, so you can be assured
`oi getting coverage ior pr escription r eiills even when
`your e away ir om home. For convenience, members
`can choose to use a mail-or der pharmacy program.
`This service is especially useiul
`to members with
`long—term health conditions who need the same
`medicine on an ongoing basis.
`
`Emer gency medical costs ar e cover ed —no matter
`where you travel. When you receive emergency
`medical services ir om a networl< ur gent car e center
`or emergency r oom, your e cover ed. Y ou‘r e also
`covered ior emergency car e r eceived ir om non-
`network providers or hospitals anywhere in the
`world. Just carry your Medica ID car d wilh you and
`travel with coniidence.
`
`Great customer ser vice. No matter which plan you
`choose, you'll
`iind that whenever you have a
`question — whether it‘s about beneiits, service or
`any other aspect oi your health car e coverage —
`you'll get pr ompt, helpiul and courteous answers
`irom Customer Service. We are very proud that our
`customer satislaction rates ar e consistently high.
`
`Our commitment to quality r ecognized. Medica
`has r eceived "excellent" accreditation status ir om lhe
`
`Nalional Committee ior Quality Assurance (NCO A"’],
`the nation's leading sour ce ior evaluating the quality
`oi managed car e plans. Medica's excellent status is
`the NCQA ‘s highest rating.
`It means that Medica
`meets strict NCQA standar ds and has exceptional
`programs ior continuous quality impr ovement
`
`

`
`QUESTIONS 8: ANSWERS
`
`ABOUT MEDI CA EL EC|'® AND
`
`MEDICA ESSENTIA L“ PLANS
`
`Do I have to select a primar ycar e doctor
`or clinic when I enr ol?
`
`Yes.Y ou and any cover ed lamily members do need
`to choose a primary car e clinic. Family members can
`choose dil ler ent clinics, and you may change clinics
`within your care system plan during the course ol
`the year. Customer Service can pr ovide you with the
`requirements and pr ocedures lor changing clinics il
`you wish to do so.
`
`Do I need to call Medica befor er eceiving ser vices?
`Generally, no. However,
`to assure that you receive
`appropriate care, a limited number ol services, pr escn'p tion
`medications and medical supplies require that you obtain author-
`i.:ation belore receiving them. For a complete list you may call Medica‘s
`Customer Service.
`
`Do I need a r efer ralfr om my primar ycar e clinic or doctor to see a specialist in my network?
`Your primary car e clinic coor dinates all ol your health car e services. In most cases, to r eceive the highest
`level ol coverage, you will need to be r elerr ed by your clinic or doctor to a specialist.
`
`However, there are some exceptions. Y ou have dir ect access to the lollowing within your Medica Elect '”
`or Medica Essential
`network:
`
`- Urgent care centers
`- OB4/GYN doctors
`
`I Mental health/substance abuse pr oviders
`- Optometrists or ophthalmologists once a year lor a routine, pr eventive eye exam.
`
`Can I see non-network pr oviders?
`You ar e covered lor emergency car e pr ovided by non-networl< doctors or hospitals anywhere in the world.
`llyour doctor relers you to a specialist who is not in the Medica Elect"’ plan or Medica Essential plan
`network, contact Customer Service prior to seeing the specialist to learn how your car e will be cover ed.
`
`Check the Summar y of Benefits for each Medica Elect“ plan or Medica Essential” plan to get
`additional infor mation on cover ed services and applicable copays.
`
`

`
`CHOOSI NG A PRIMARY CARE DOCTOR
`
`Medica encourages you to develop a long—terrn r elationship with one doctor
`
`forr outine car e. That doctor will become familiar with your health, family
`
`and treatment history , which is very helpful when pr oviding car e. And you
`
`will likely feel mor e comfortable seeing the same doctor over time,
`
`instead
`
`of having a new doctor at each visit.
`
`Here ar e the thr ee most common types
`of primary care doctors:
`
`Family practice doctors. These doctors specialize
`in taking car e ol the general health needs ol people
`olall ages, lr om inlancy thr ough adulthood. They ar e
`trained in six br oad ar eas ol medicine: pediatrics,
`internal medicine, sur gery, obstetrics and gynecology ,
`psychiatry and community medicine.
`
`Inter nists. These doctors specialize in the diagnosis
`and tr eatment ol diseases in adults. They do not
`perlorm surgery, deliver babies or tr eat childr en.
`
`Pediatricians. These doctors specialize in taking
`car e ol the general health needs ol children, lron
`birth thr ough about age ‘lb.
`
`In addition, you have dir ect access to obstetrician-
`gynecologists within your car e system. These
`doctors specialize in pr egnancy and childbirth, and
`in the diseases and r outine physical car e related to
`a woman’ s reproductive system.
`
`Some 'l:hings to consider when choosing
`a primar y care doctor:
`
`The doctor '5 training and experience. You wantto
`be com lortable that your doctor has the kind ol
`training and experience that is right lor you. Ask
`about his or her experience with ar eas olmedicine
`thatmay be ol special concern to you or your lamily.
`
`The doctor ‘s accessibility . You wantyour doctor to be
`available when needed. Find out the ol lice hours and
`
`how long it takes to schedule a r outine visit. Ask who
`covers lor the doctor when he or she is out ol town.
`
`The doctor ‘s appr oach to pr eventive medicine.
`You want a doctor who emphasizes staying healthy .
`Note whether the doctor asks you about your lood
`choices, exer cise habits, smoking and alcohol
`
`intake, as well as about any health
`risks you may be exposed to on
`the job or at home. Does the
`doctor r ecommend preventive
`care services such as r outine
`
`physicals, immunizations and mammograms? Does
`the doctor answer your questions about how you
`can make healthy impr ovements in your lilestyle?
`
`ll you want help in choosing a primary car e doctor,
`call Medica Calltink {Medic a‘s nurse line. A r elerral
`specialist will help you lind the doctor who best
`meets your needs.
`
`MEDI CA CallLink *’
`24-hour Nurse Line
`Answers You Health Questions.
`
`One ol Medica‘s most popular leatur es is our nurse
`line, Medica CallLink "’. This 24—hours—a—day , 3o5clays—
`a-year service is stalled by registered nurses who are
`ready to answer your questions on a variety ol medical
`topics and situations.
`Medica Calltink "‘ nurses answer thousands ol calls
`
`each year lr om Medica members.They give advice
`on a wide range ol concerns, lr om how to find a
`heal thr elated support gr oup to how to tr eat a minor
`burn or remedy a child's slully nose.
`
`lind that quick, sound
`With Medica C.al|Link '”, you'll
`medical guidance is only a phone call away.
`Medica CallLink *3:
`1-BOD-962-9497
`
`Hearing-impair e:l {TTY) callers:
`952-992-2357
`or1 -300-23:1» E319
`
`

`
`OUR GOAL IS TO HE LP OUR MEMBERS STAY HEALTHY
`
`At lvledica, our goal is helping you stay healthy .T o that end, we offer members a wide
`
`variety of health education information as well as personalized assistance for members with
`
`certain chr onic diseases. W e encourage you to become an informed consumer of health car e
`
`services and to take full advantage of cover ed prevcntivc car e services.
`
`HEALTH EDU CATION INFOR MATION
`
`l‘.r'iu;'clr'ct'i Horiltl: Huiaclboolc. This awar da.-winning sell-
`car e health manual helps you take a more active r ole
`in your health. It covers common health topics, such
`as allergies, bacl< pain, ear inlections and rashes,
`and many other health conditions and symptoms.
`Under each topic, you'll lind detailed inlormation on
`home tr eatm en ts and pr even tion, as well as in lorm a tion
`about when to call a health car e pr olessional.
`
`Member publication. Hz=..=i-J'rl1y Arrirucles“ . Medica
`members are mailed a quarterly publication called
`Healthy Atfitudefi It contains uselul health educa —
`lion iniorrnation, pr eventive car e r eminders, ben —
`elits iniormation and mor e.
`
`24-hour nurse line. Medica CallLinl< '”
`
`is a nurse
`
`PREVENTIVE CARE
`
`line service available to members 24 hours a day
`by telephone.
`Hea|1:hFor ums Online. Go tow'w'w _medica_com and
`
`click on the link lor HealIhForums to get iniormation
`about minor illnesses and injuries, routine and
`trgent health situations, nutrition, litness and med —
`ications. The site provides access to an easy—to-use
`medical encyclopedia and dictionary , pr escription
`drug inlormation, symptom guide, leatur e articles
`and summaries oi medical journal articles.
`
`Medica strongly believes that appr opriate health
`scr eenings and immunizations ar e vital ways lor you
`to maintain your health.
`
`We work with you and your doctor to inlorrn you
`about r ecommended timelines and ages lor health
`screenings. Likewise, we encourage you to work
`with your doctor to stay curr ent with screenings
`and immunizations.
`
`

`
`CARE MANAGEMENT SER VICES
`
`"Car e management" is a gr oup ol services Medica
`provides to make sur e you obtain appr opriate car e
`and to assist in coor dinating benelits and services.
`Car e management is an important component oi
`promoting wellness and includes the lollowing:
`
`0 Prior authorization ol certain services,
`medications and medical supplies.
`
`- Utilization management.
`
`0 Case management lor individuals with
`complex and catastr ophic health pr oblems.
`
`0 Disease management lor members with
`diabetes, asthma and other chronic illnesses.
`
`- Discharge planning.
`Prior authorization. Prior authorization is a r eview
`oi a limited number ol services, medications or
`medical supplies conducted in advance ol pr oviding
`the service or treatment.
`It
`is intended to deter-
`
`mine their medical necessity‘ — and to make sur e
`that the car erequested is needed and appropriate
`and will be deliver ed in the proper setting lor
`the optimal length ol time. The r eview also ensur es
`that
`the services are covered under your plan
`benelits. You may appeal an authorization decision
`that you or your doctor disagree with. See an
`outline of the appeals process in materials that
`accompany this br ochure or call Customer Service
`lor additional inlormation.
`
`Utilization management. Uti