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

WPS Metro Choice Southeast
(800) 634-6448
wpsic.com/state
Not Available
Overall Quality Rating
See Report Card section
What’s New for 2013
WPS is pleased to announce an expansion.
Metro Choice Southeast now includes
Dodge and Jefferson counties.
WPS will offer a health risk assessment to
include biometric screening. Biometric
screening determines the risk level of an
individual for certain diseases and other
medical conditions. By knowing risk levels, an
individual can better make decisions related
to health and wellness.
Provider Directory
Go to wpsic.com/state/pdf/dir2013_metro_
choice_southeast.pdf to search for a
provider. You may also contact WPS at (800)
634-6448 to request a copy.
How Metro Choice is Unique
Metro Choice is an attractive alternative
to HMO plans, with coverage for medical
services received outside of your network at
a lesser benefit level (see below).
Referrals and Prior Authorizations
Referrals are not necessary under this plan.
If you use providers outside the WPS Metro
Choice network, you do not need a referral
but the services are subject to a deductible
of $1,000 individual/$2,000 family and then
payable at 70%.
Prior authorization is recommended for any
of the following services:
Prior authorization is
required for lower back
surgery and high-tech
radiology services.
Members may
also request prior
authorization for any
service to ensure
coverage. WPS will
notify you and your
provider in writing of
its decision on the
authorization request.
Qualified Plan
Non-Qualified Plan
See Glossary for definitions
Care Outside Service Area
In-network hospital emergency rooms
or urgent care facilities should be used
when possible. If you are unable to reach
an in-network provider and cannot safely
postpone the care until you are able to
return to the service area, go to the nearest
appropriate medical facility and contact
WPS member services as soon as possible.
Mental and Behavioral Health Services
Medically necessary services are available
when performed by licensed mental health
professionals practicing within the scope of
their licenses.
Dental Benefits
No routine dental coverage provided.
• New medical or biomedical technology;
• Methods of treatment by diet or exercise;
• New surgical methods or techniques;
• Organ transplants;
• Durable medical equipment over $500;
• Pain management injections.
Health Risk Assessment Information for Enrolled Members:
Contact Mark Mitchell at (800) 333-5003
Decision Guide Page 58