It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

Gundersen Lutheran Health Plan
(800) 897-1923 or (608) 775-8007
glhealthplan.org
What’s New for 2013
Gundersen Lutheran Health Plan (GLHP)
wants you to have up-to-date test results
to help you and your healthcare provider
make decisions about your care. In 2013,
GLHP will offer an incentive to adult
members who complete an online health
assessment, as well as health screenings.
Screenings will include fasting glucose,
cholesterol, blood pressure and body mass
index (height and weight). Did you know,
GLHP ranked in the Top 100 health plans in
the country by the National Committee for
Quality Assurance (NCQA)?
Provider Directory
To view or print a copy of the provider
directory, go to glhealthplan.org/etf; click
on 2013 Provider Directory. To access the
most current practitioners and facilities, a
searchable online directory is also available
at glhealthplan.org/providerdirectory. You
may also call customer service at (800)
897-1923 or (608) 775-8007 to request a
provider directory or to find a provider in
your network.
Referrals and Prior Authorizations
A member may seek services from any
GLHP network provider without a referral.
If your GLHP provider feels that you require
specialty care outside of the network, he/
she must complete a referral request form
and submit it to GLHP. Selected medical
procedures and services, including
high-tech radiology and low back surgery,
require prior authorization. Your provider
should submit a written prior authorization
request to GLHP. GLHP will respond in writing
to you and your provider after reviewing the
referral or prior authorization request.
Overall Quality Rating
See Report Card section
Care Outside Service
Area
In the case of an
emergency or urgent
medical condition, you
should seek care from
the nearest provider
equipped to handle
your condition. You must
receive urgent care
from a plan provider
Qualified Plan
if you are in the plan
Non-Qualified Plan
See Glossary for definitions
service area, unless
it is not reasonably
possible. Please notify GLHP within 24 hours
if admitted to a hospital. All other care must
be with a plan provider, unless GLHP has
approved a referral as described above.
Mental and Behavioral Health Services
Referrals are not required for services
received from a GLHP behavioral health
provider. Prior authorization is required for
transitional services.
Dental Benefits (See plan for full details.)
Preventive Services: Covered at 100%:
Exams, prophylaxis, fluoride (to age 18),
sealants (to age 18) and X-rays, two per
calendar year, subject to the $500 annual
benefit maximum.
Restorative Services: Covered at 80%:
Bridgework, implants, dentures, crowns and
root canals.
Annual Benefit Maximum: $500 per person
per calendar year.
Orthodontics: None.
Dental Network: You can go to any dental
provider, and the services are not subject to
a usual and customary fee schedule.
Health Risk Assessment Information for Enrolled Members at:
glhealthplan.org/assessment
Decision Guide Page 38