a newsletter for unity members - Unity Health Insurance

unityhealth.com

a newsletter for unity members - Unity Health Insurance

A NEWSLETTER FOR UNITY MEMBERS

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This March,

learn more

about Colon

Cancer

prevention

See page 4

Motivational tips

to help reach

your goals

page 3

page 5

Try this quick to

mix healthy dip

page 7

Fill it in & Win

Program

winners

page 8


TM

Fitness First & More Reimbursements

IN THIS ISSUE

Fitness First & More Reimbursements...............

Nurse Practitioners and Physician.....................

Assistants—A Part of Your Health Care Team

Using a Participating Physician..........................

Programs to Help Manage Your Health..............

Unity’s Member Rights ......................................

and Responsibilities Statement

WEBSITE CORNER...........................................

Meet Unity’s Team through

the New Employee Spotlight

Good Health—It Starts With Your Heart

Benefit Information Available Online

Taking Action—Motivational Tips to ..................

Maintain Energy and Focus

March is Colon Cancer Awareness Month........

What About Virtual Colonoscopy......................

New Low Volume Colonoscopy Prep..................

Solution Added to Unity’s Formulary

Too Much Salt.....................................................

Quiz on Finding Sodium in Your Diet.................

Quick Facts on Salt............................................

Tips for Reducing Sodium in Your Diet .............

Utilization Management .....................................

What is Unity’s Step Therapy Program............

FORMULARY UPDATE.....................................

Unity Continues to Provide ...............................

Top Notch Service

HEALTHY RECIPE.............................................

Garlicky Greek Yogurt Dip

Complaints and Grievance Resolution...............

Congratulations to Our ......................................

Fill It In and Win Program Winners

CONTACT INFORMATION

• For questions, contact

Unity Customer Service at:

– Ask an Expert within MyUnity

at unityhealth.com

– 800-362-3310

• For paper copies of any materials,

please call 800-548-6489

Unity News is distributed quarterly by

the Unity Marketing Department.

Editor:

Lindsay Mayer

Art Director: Dorothy Harms

Comments and suggestions are welcome.

Contact: Marketing, 840 Carolina Street

Sauk City, WI53583

800-362-3308

communications@unityhealth.com

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In January, we introduced our new wellness program,

Fitness First & More. Through this new program you can

receive rewards and reimbursement for participating in

activities such as Fitness First for cash, health education

classes, integrative medicine services, community

supported agriculture and Weight Watchers®.

If you are participating in Fitness First for cash, your

health club will submit your workouts to us each month

following your one-time enrollment in the program. To

enroll, visit unityhealth.com and click Health & Wellness,

then Fitness First & More and then Fitness First. For the

other activities, you will need to complete the Fitness

First & More reimbursement form and send it plus any

required receipts to us to receive your reimbursement.

The reimbursement dates for all activities including

Fitness First in 2011 are May 13, August 15 and

November 15. To receive a reimbursement on one

of these dates you will need to submit any required

documentation to us by the end of the quarter prior

to the reimbursement date. For example, to receive

your reimbursement on August 15, we will need to

have all of the required documentation by June 30.

For more information about Fitness First & More

and how to receive your reward/reimbursement,

visit unityhealth.com and click Health & Wellness

and then Fitness First & More.

Nurse Practitioners and Physician Assistants—

A Part of Your Health Care Team

It’s important for you to have a primary care physician (PCP). As the leader of your health care team, he/she

maintains and coordinates your overall care.

In addition to your PCP, other primary care practitioners like nurse practitioners and physician assistants are

important players in your health care team. Nurse practitioners and physician assistants are available to help with

routine exams, urgent/problem visits, management of chronic conditions and follow-up care. After seeing you they

consult with your PCP. This collaborative approach makes sure you have the best health outcome.

So, the next time you have a health concern, remember, a nurse practitioner or physician assistant may be able to

help you when you have health care needs.

Using a Participating Physician

As a Unity member, you have the right to select a primary care physician (PCP). A PCP helps coordinate your health

care services. If you have a Health Management Organization (HMO) plan with Unity, it is important to select a

PCP that is participating or in-network to have coverage for your services. If you select a non-participating or

out-of-network physician, Unity will assign you a participating or in-network physician that is close to your

residence. As an HMO member, if you receive services from a non-participating or out-of-network physician and you

did not receive approval from Unity to do so, you may be responsible for these charges.

To determine if a physician is participating or in-network for your plan, please go to unityhealth.com

and click Find a Doctor.

Programs to Help Manage Your Health

Unity offers a variety of programs to help you manage your health if you have a chronic condition.

These include health management programs, complex case management and additional education programs.

The health management programs we offer include:

Asthma

Diabetes

Depression (chronic, situational or postpartum)

9 Months & More (prenatal/postpartum)

Attention-Deficit/Hyperactivity Disorder

(ADHD)

Anxiety

Hypertension

Each health management program offers

educational opportunities, resources, self-management

and screening reminders.

In addition, there are educational options available if you

are dealing with ongoing issues:

Living Well With Chronic Conditions—Behavioral and

coping skills are taught in a supportive atmosphere

Active Living and Learning—Lifestyle habit and

behavior change program for those diagnosed with glucose

intolerance, metabolic syndrome or Type 2 diabetes within

the last 12 months and are not on any medication

If you would like more information about these programs,

visit unityhealth.com and select Health & Wellness and then

Manage Your Health or call Unity’s Health Services

Department at 866-884-4601.

UnityNews is a quarterly publication used

to inform Unity members about policy and

benefit news and to provide members

with information on current health matters.

Articles in this newsletter are edited and reviewed by

experienced health professionals. They are not intended to

replace professional medical advice, and opinions expressed are

not necessarily those of Unity. Judgements regarding individual

health problems should be discussed with your Unity physician.

Unity’s Member Rights and Responsibilities Statement

We are committed to maintaining a mutually respectful relationship with our members and practitioners. Our

Member Rights and Responsibilities Statement communicates our respect for your rights and our expectations of

your responsibilities including your right to privacy and confidentiality, your right to be treated with respect and

dignity and your responsibility to show consideration and respect to health plan staff and health care practitioners.

To view Unity’s Member Rights and Responsibilities Statement, go to unityhealth.com, select Members,

Using Your Plan and then See Member Rights & Responsibilities.

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Meet Unity’s Team through

the New Employee Spotlight

Benefit Information

Available Online

Website Website

Corner Corner

At Unity, our philosophy is to provide you with excellent

customer service and to exceed your expectations in

everything we do. We wouldn’t be able to achieve our goals

without our team. Because they are so important, we’ve

created a new Employee Spotlight to share them with you.

Each month, you’ll find a different employee featured on

our website. Learn more about his/her role in providing you with

great service. Plus, you’ll even find some fun and interesting facts.

So, to see who’s in the spotlight this month, visit unityhealth.com and click

About Unity and then Employee Spotlight.

We’re excited to share information with you about the individuals who make

our team so great!

Good Health—It Starts With Your Heart

Having a healthy heart is an important step to leading a healthy lifestyle. To have a

healthy heart, you need to focus on exercise, nutrition and getting regular checkups.

This isn’t something you can do overnight. The key is to set goals and take

small steps to achieve them.

To help you get started on your journey to better heart health, we’ve put

together some key information about the importance of exercise, getting regular

check-ups, recipes to help you and your family eat healthy as well as other

resources to keep your heart in good shape. Also, learn more about the American

Heart Association’s Go Red for Women® and follow the individuals participating

in the Girlfriend’s Challenge as they share their personal stories of how they’re

working to improve their heart health.

Take care of your heart. Start by visiting unityhealth.com today! Just click

Health & Wellness and then Preventive Health.

Looking for information about your Unity health plan Everything you need to

know is available at unityhealth.com. Just click Members, then Member Kit and

then select your member type. Here you can find the information you need to help

you understand your benefits and access care.

• Certificate of Coverage—This document provides information such as covered

and excluded benefits and services, restrictions on services outside of Unity’s

service area and how to submit a claim. (Members covered under the State of

Wisconsin health insurance program are directed to their It’s Your Choice

Reference Guide.) To view your Certificate of Coverage, log into MyUnity.

• Pharmacy Information—Learn more about your prescription drug benefits

including what drugs are covered as well as how to receive them, if applicable.

View this information by clicking the Prescription Medication tab. (Members

covered under the State of Wisconsin health insurance program should contact

Navitus Health Solutions at navitus.com to learn more about their prescription

drug benefits. BadgerCare Plus members should contact the State Medicaid

program at 800-362-3002.)

• Schedule of Benefits—Review your benefits to understand what copayments

and other charges you may be responsible for when seeking care. To view your

benefits, log into MyUnity. (Members covered under the State of Wisconsin health

insurance program are directed to their It’s Your Choice Reference Guide.)

• Find A Doctor—Use the look-up feature, as well as the help section, to assist

you with finding participating primary care physicians, specialists, urgent care

facilities and hospitals.

• Member Guide—This reference tool helps you understand how to obtain

primary, specialty and emergency care; how to obtain care after normal office

hours and care outside of the service area; how to obtain language assistance;

how to voice a complaint; how to appeal a decision; information on how Unity

evaluates new technology and other health plan information. Read this guide by

clicking the Using Your Health Plan tab, then Using Your Plan and then Unity

Member Guide.

Taking Action—Motivational Tips to Maintain Energy and Focus

Are you stuck in a rut Are you feeling like the enthusiasm you had when you made

that New Year’s Resolution is a distant memory Relax. We have all been there.

Here are some tips to help you get re-focused and re-energized:

Choose one area of focus. While you may have many things you want to work on,

start by identifying one main area. If you try to change too many things at once it

can lead to feeling overwhelmed and setting yourself up for failure.

Think about strengths you have and the times in your life when you have been

successful at this or another change. What worked What can you draw from

those experiences

Identify your specific goal. Make it a SMART goal:

– Specific – list exactly what you want to achieve instead of “I want to lose weight,”

it should be: “I will lose 10 pounds (specific) over the next two months (specific).”

– Measurable – losing some weight sometime is not measurable, but losing 10

pounds in two months is measureable. You can determine if it happened or not.

– Attainable – losing 10 pounds this week is not attainable (at least not for most

and certainly not a good way to keep it off); however, losing 10 pounds over two

months is very achievable.

– Realistic – 10 pounds in a week is not realistic, and you may end up feeling

more like a failure than a successful weight manager. Losing weight sometime,

while it could happen, most likely will not happen.

– Timely – setting a definite period of time will help you to plan for small

steps to track your progress. It also gives you an endpoint so you can

determine if you achieved your goal or if you need to adjust your

strategy or your goal.

Write down your goal and post it where you will see it every day.

Visualize yourself having accomplished the goal. How do you feel

Who is celebrating with you

Identify the challenges or what might get in the way. This gives

you the opportunity to prepare for any obstacles you might

encounter and have a plan for dealing with them.

Write down your action steps. What specific things do you need to do to get

you from where you are now to where you want to be Make them small,

manageable steps. Think about what you can do today or this week to move

you toward your goal.

Focus on the process and not just the results. Don’t get caught up in how long

it is taking to reach your goal. Be in the present moment and appreciate all you

are doing each day.

Be accountable. Tell others about your goal and have a buddy check-in with you

on your progress.

Join a support group of others working on similar goals to share ideas, challenges

and victories.

Use post-it notes for reminders of your goal, positive self-talk statements, or

words of wisdom and inspiration. Read them aloud daily!

There is no such thing as failure – don’t beat yourself up. Learn from each

experience and use them as a chance to re-evaluate your goal. Is it realistic or

does it need to be modified

Celebrate your successes and milestones!

For help setting goals, use the Wellness Goal Setting Worksheet available at

unityhealth.com by clicking Health & Wellness and then Interactive Health Tools.

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March is Colon Cancer

Awareness Month

By: Jennifer Weiss, MD, Clinical Instructor, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine & Public Health and

Patrick Pfau, MD, Associate Professor of Medicine, Chief of Clinical Gastroenterology, University of Wisconsin School of Medicine & Public Health

March is colon cancer awareness month and a perfect opportunity to underscore

the importance of colon cancer screening. While the overall rate of colon cancer

deaths has decreased over the last few decades, it remains the second leading cause

of cancer-related deaths for both men and women in the United States. What

makes that more astonishing is that we have the capability to prevent colon cancer

with currently available screening tests.

Colorectal cancer tests can be divided into two types:

1. Tests of early detection

Stool tests such as fecal occult blood tests (FOBT) and fecal

immunochemical tests (iFOBT)

Studies show that when correctly performed they can decrease

colon cancer death rates by up to 30%

2. Tests with the potential for both early detection and prevention

Tests that examine the colon such as flexible sigmoidoscopy, optical

colonoscopy, and virtual colonoscopy

Can lead to colon cancer prevention by identifying pre-cancerous lesions,

also known as adenomatous colon polyps

Polyps can be removed from the colon during optical colonoscopy

Studies suggest flexible sigmoidoscopy can decrease colon cancer deaths

by close to 75%

Studies suggest periodic optical colonoscopy has the potential to decrease

colon cancer mortality by almost 90%

Colorectal cancer screening is powerful and unique because it is cancer

prevention due to the ability to visualize and remove pre-cancerous polyps

before they progress to cancer.

Colonoscopy is a test where the entire colon is looked at using

a flexible tube with a built-in camera and light and colon polyps can

be removed at the same time. A colonoscopy takes about 20 minutes

to perform. The patient preps his/her bowel the night before the test.

During the test procedure there is minimal to no discomfort since sedation

is usually given. If a pre-cancerous polyp is found during the procedure it can

be removed at the time of the colonoscopy, providing both diagnosis and therapy

to prevent colon cancer. Afterwards, the practitioner will discuss what was found

on the colonoscopy and what future screening is required. Most patients do not

needing further colon cancer screening for 5-10 years.

Colon cancer awareness month provides a reminder to all members of the

importance of getting screened for colorectal cancer and polyps. Please contact

your primary care physician to set up an appointment.

For more information about colorectal cancer prevention, screening, and

options, visit unityhealth.com and click Health & Wellness and then Preventive

Health and then Preventive Screenings. Or, visit uwhealth.org/coloncancerscreening.

Learn more about colorectal cancer by visiting unityhealth.com.

Here you’ll find information about prevention including a link to

UW Health’s new Colon Cancer & Prevention Site which includes:

Information about preventing colorectal cancer through lifestyle

and screening

An in-depth comparison of different types of colorectal cancer

screening tests

Resources for scheduling and preparing for a screening

Videos examples of Virtual and Optical Colonoscopies

Patient testimonials

What About Virtual Colonoscopy

By: Perry J. Pickhardt, MD, Professor of Radiology, Chief of Gastrointestinal Imaging,

University of Wisconsin School of Medicine & Public Health

Virtual colonoscopy (VC), also referred to as CT colonography, is a minimally-invasive

screening test for colorectal cancer. VC is a safe, accurate, and convenient alternative

to optical colonoscopy. A bowel preparation is performed the night prior. The exam

itself takes about 10-15 minutes and, unlike optical colonoscopy, does not require IV

medications. Because there is no IV medication patients can drive themselves home and

can immediately return to their regular activities. The VC screening program at

University of Wisconsin Hospital and Clinics remains unique since it is the only site in

the U.S. with broad insurance coverage. Unity has covered VC screening for its members

since 2004.

With few exceptions, any adult age 50 years or older is an appropriate candidate for

VC screening. This includes all generally healthy individuals due for screening, with or

without a family history of colorectal cancer, as well as individuals at increased risk for

colonoscopy or taking blood thinners. For more information, please call the University

of Wisconsin Hospital and Clinics VC Program office at 608-263-9630 or visit

uwhealth.org/virtualcolonoscopy.

New Low Volume Colonoscopy Prep

Solution Added to Unity’s Formulary

MoviPrep, a bowel preparation solution, has been added to Unity’s prescription drug

formulary. MoviPrep is a lower volume bowel preparation that may be easier to take than

other bowel preps. The fact that it’s lower volume may be an important factor to consider

when scheduling your colonoscopy. If you have prescription drug coverage through

Unity, you can now ask for a prescription for this prep solution if it is the right product

for you. For more information about Unity’s prescription drug formulary, visit

unityhealth.com and click Members and then Drug Formulary under Quick Links.

Please Note: This is not applicable to members covered under the State of Wisconsin health insurance program or the

BadgerCare Plus program. State of Wisconsin members should contact Navitus Health Solutions at navitus.com and

BadgerCare Plus members should call the State Medicaid program at 800-362-3002.

4 I S S U E 1 / 2 0 1 1


Too Much Salt

Are you getting too much salt You may not think so but every day nine out of

10 Americans eat too much salt. You could be eating too much without knowing

it because about 77% of the salt we eat is in the food we buy. “Sodium has

become so pervasive in our food supply that it's difficult for the vast majority of

Americans to stay within recommended limits,” said Janelle Peralez Gunn, public

health analyst with the Centers for Disease Control and Prevention (CDC).

We need some salt to maintain the body’s fluid balance. Salt helps muscles and

nerves to function properly. But eating too much salt can raise blood pressure,

which may lead to heart failure, heart attack, kidney failure and stroke. The

average American’s salt intake each day is around 3,500 mgs. New salt use

guidelines in 2010 recommend 2,300 mg per day, which is about one teaspoon

of table salt. For people who are more sensitive to the effects of salt like those

with hypertension, African Americans, and middle-aged and older adults, the

daily limit intake recommended is 1,500 mg of sodium per day.

According to a CDC survey, grain-based foods, typically snack foods, account

for the biggest proportion of salt in the American diet—36.9 percent of the total

average intake. The second largest amount of salt is found in foods containing

meat, chicken and fish like processed sandwich products and frozen entrees.

These account for 27.9 percent of the total average intake.

Together, these two categories account for nearly two-thirds of the daily salt

intake in the American diet.

If you want to cut down, the good news is there are plenty of simple things

you can do. See Tips for Reducing Sodium in Your Diet.

Quiz on Finding Sodium in Your Diet

Test your knowledge about sodium. Read the statements below and

determine if they are true or false.

1. If you’re trying to watch your sodium intake, eating a can of soup at

lunch is a good alternative to a hamburger and fries.

2. Frozen dinners are good choices when you're trying to eat less sodium.

3. Herbs, spices, and salt-free seasoning blends are better for cooking

and putting on the table.

Answers: 1. False, 2. False, 3. True

Quick Facts on Salt

Another name for salt is sodium.

The most common form of sodium is table salt.

Most of the salt we eat comes from processed foods.

Check food labels. Sodium is in some foods you might not expect,

such as soy sauce, some antacids, cereals and bread products.

Eat no more than 2,300 mg of sodium a day from all foods—

about one teaspoon of salt.

Tips for Reducing Sodium in Your Diet

The Nutrition Facts label that appears on food packages lists the “% Daily Value” for sodium. Look for the abbreviation “%DV” to find it. Foods listed as 5%

or less for sodium are low in sodium. Anything above 20% for sodium is considered high. Try to select foods that provide 5% or less per serving.

Fresh Fruits and Vegetables

Eat more fresh fruits and vegetables. They are naturally low in

sodium and most have no sodium.

Bonus Tip: Bananas, leafy green vegetables and fruit

from vines contain natural sources of potassium, which

act to balance the effects of sodium on blood pressure.

Cereal

Choose ready-to-eat breakfast cereals that are lower in sodium. Some

brands of corn flakes have up to 266 mg of sodium per cup. Some brands of

raisin bran have up to 342 mg of sodium per cup.

Bonus Tip: Puffed rice and puffed wheat are sodium free. Mix half of your

favorite cereal with half of a sodium-free choice.

Meats

Use fresh poultry, fish, and lean meat, rather than canned,

packaged or processed types. Cook a turkey breast and freeze a portion

for use later. Slice the rest for simple sandwich options.

Bonus Tip: A deli meat labeled “lite” may actually have more sodium than the

higher-fat version; it may only have less fat. Some brands have 50% less

sodium. Be a label reader.

Seasonings and Condiments

Use herbs, spices, and salt-free seasoning blends in cooking and at the table.

Kosher salt, sea salt and other specialty salts are just that — salt. Remember

to include them in adding up your sodium intake for the day.

Marinades and flavorings are known for containing large amounts of sodium.

Teriyaki sauce (1 tablespoon) contains 690 mg of sodium, and soy sauce

(1 tablespoon) may contain up to 1,000 mg of sodium.

Bonus Tip: Use low-sodium soy sauce sparingly. It still contains a lot of

sodium. Go for vinegar, lemon juice or olive oil on your salad — they naturally

have less sodium. Try orange or pineapple juice as a base for meat marinades.

Condiments and salad dressings are full of salt. Ketchup (1 tbsp) = 178 mg;

Sweet relish (1 tbsp) = 121mg; Capers (1 tbsp) = 255 mg.

Bonus Tip: Use low-sodium or sodium-free condiments or try sprinkling a

sodium-free herb-blend on your sandwich or salad. Cranberry relish or apple

butter also makes for a naturally lower sodium choice.

Side Dishes

Cook rice, pasta, and hot cereals without salt.

Bonus Tip: Cut back on instant or flavored rice, pasta, and

cereal mixes, which usually have added salt.

Cut back on frozen dinners, pizza, packaged mixes, and

canned soups or broths — these often have a lot of sodium.

Rinse canned foods, such as tuna and vegetables to remove

some sodium.

Bonus Tip: Buy cans labeled “no salt added,” and add your own salt, in

moderation. Check the freezer section where you will find unsalted choices.

Vegetable juices are a healthy way to get your vegetables in, but a smarter

choice would be to choose the low-sodium version. One cup of regular

vegetable juice cocktail contains 653 mg of sodium.

Snacks

Nuts contain a lot of sodium because they are often processed

with salt in the roasting process. An ounce of dry-roasted, salted peanuts

contains 230 mg of sodium. The same size serving of dry-roasted, salted

mixed nuts has 190 mg.

Bonus Tip: Buy the unsalted variety, which are practically sodium-free.

Snacks are nearly always high in salt. Potato chips (1 oz.) = 149 mg;

Cheese puffs (1 oz.) = 258 mg; Pretzels (1 oz.) = 385 mg.

Bonus Tip: “Baked” or fat-free snacks can have the same amount of

sodium or more as the regular product, so read the label.

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Utilization Management

The philosophy of managed care is to provide information and preventive services

to help members be as healthy as they can be while managing the cost of care.

Healthy members are less likely to need expensive medical care. As part of the

managed care process, Unity works with its participating physicians to ensure that

care recommended for members includes the most appropriate and effective

treatments available. This process is called “care management” or “utilization

management” and is conducted by nurses with the support of physicians. Unity has

programs directed at evaluating the utilization and quality of health care services.

One of Unity’s roles as a managed care organization is to provide you with

educational materials to help you make the best use of your health benefit. This

includes available preventive care services such as immunizations and screenings

(mammograms, pap smears or colonoscopy). We also provide information about

fitness and wellness programs. Your responsibility is to read the materials, follow

the health measures that apply to you and your family and become familiar with

your plan benefits.

Your Primary Care Physician (PCP) plays an important role in your health.

Your PCP is responsible for providing primary care services and for coordinating

your health care. At times when you need care from a specialty provider, your PCP

can refer you to a Unity participating provider. Working through your PCP for

referrals, when needed, ensures that your medical claims are processed according

to your benefits.

One of the most important components of care management involves Unity

working with medical management, pharmacy, behavioral health groups and your

PCP. These group efforts ensure you receive the most effective treatment available.

The UW Medical Foundation (UWMF) provides medical management services

for members.

UW Behavioral Health provides behavioral health management services for

members. They also coordinate alcohol and other drug abuse (AODA) services

for regional members.

Gateway Recovery provides AODA management services to Dane County

members.

Unity provides utilization management for chiropractic care.

The Unity Pharmacy Program provides comprehensive clinical pharmacy

services for all members receiving prescription benefit coverage through Unity.

Additionally, medication utilization management services are provided for

medications covered under the medical benefit for all members.

All of the utilization management programs are staffed by qualified health

professionals and supported by physicians with education, training and experience

related to the utilization management reviews they conduct.

In an effort to assess the clinical appropriateness of hospital and other services, the

medical management staff utilizes clinically-based decision support criteria. UWMF

uses InterQual criteria along with UWMFpolicies and procedures.

The first source of decision criteria used for medical care is InterQual, an essential

tool that assists health care organizations in balancing cost and quality across the

continuum of care. InterQual, a nationally recognized set of criteria, is designed

for managed care organizations, hospitals, insurers and provider organizations.

InterQual helps determine if the proposed services are clinically indicated, provided

at the most appropriate level and setting and whether further evaluation is required.

Other care guidelines or criteria utilized include:

Gateway Recovery: American Society of Addiction Medicine (ASAM)

UW Behavioral Health: The Mihalik Group’s Medical Necessity Manual for

Behavioral Health and the American Society of Addiction Medicine Patient

Placement Criteria

The Unity Pharmacy Program applies criteria specific to each individual drug

requiring prior authorization. The criteria is developed, approved and adopted by

a committee of pharmacists and physicians from Unity’s provider network.

The guideline-based system eliminates reviewer bias as it guides decisions about

quality, clinical care and service. The medical management teams can provide a

specific set of criteria to you upon request. You may request the guideline criteria

by contacting the appropriate medical management team.

The guideline/criteria show how health care providers across the United States

are practicing. Guidelines are supported by current medical evidence and are not a

result of corporate financially-sponsored controls. Unity monitors the utilization

management decision-making processes to ensure appropriate use. In addition,

Unity’s Utilization Management/Technology Assessment Committee (UM/TAC)

consists of plan physicians who oversee utilization management activities.

Medical management, pharmacy and the behavioral health groups are available

at least eight hours a day during normal business hours to receive and return calls

regarding utilization management issues. After normal business hours, calls are

answered by an answering machine or service and are returned the next business

day. Staff members identify themselves by name, title and organization when

receiving or returning calls relating to utilization management issues. Telephone

services for the hearing and speech impaired are provided at each affiliate site.

For questions relating to a utilization management issue, a toll-free number is

available. The numbers to call include:

UW Medical Foundation

608-821-4200 (Local)

888-829-5687 (Toll-free)

UW Behavioral Health

608-233-3575 (Local)

800-683-2300 (Toll-free)

Gateway Recovery

608-278-8200 (Local)

800-785-1780 (Toll-free)

Unity Pharmacy Program

888-450-4884 (Toll-free)

Unity Health Insurance

(Chiropractic Review)

800-362-3310 (Toll-Free)

608-643-2564 (Fax)

Unity works with participating physicians and care management staff to make

certain that decisions are based only on appropriateness of care and service. Unity

does not offer incentives to encourage underutilization or reward practitioners or

other individuals involved in the care management process for issuing denials of

coverage or service.

What is Unity’s Step Therapy Program

There are many different medications that treat the same symptoms and illnesses. These medications obtain similar results

but vary in prices. Unity’s Step Therapy Program helps provide the right medications to help keep costs down.

How the Program Works

Unity’s Step Therapy Program requires a member to try the more cost-effective medications before receiving coverage

for the more expensive medications. Many members find the first medication very effective and never need to step up

to a different medication. These medications require prior authorization for coverage and requests are reviewed on

a case-by-case basis. Each medication has specific requirements for approval. Formulary or non-formulary drugs

may be included in the program.

For more information about Unity’s Step Therapy Program and to see which medications have step

therapy requirements, visit unityhealth.com and click Members and then Using Your Pharmacy Benefits.

Please Note: This is not applicable to members covered under the State of Wisconsin health insurance program or the

BadgerCare Plus program. State of Wisconsin members should contact Navitus Health Solutions at navitus.com and

BadgerCare Plus members should call the State Medicaid program at 800-362-3002.

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F O R M U L A R Y

U P D A T E

The following drugs have changed formulary status. These changes were made between November 2010 and February 2011. Members affected by these changes received a letter from

Unity containing more details. A change in formulary status of drugs may affect out-of-pocket costs, depending on the current drug benefit. The complete formulary as well as current prior

authorization criteria and other pharmacy policies are available at unityhealth.com. Members covered under the State of Wisconsin health insurance program should contact Navitus Health

Solutions at navitus.com to learn more about your prescription drug benefits. Members covered under the BadgerCare Plus insurance program should call 800-362-3002.

Formulary Additions, Non-Additions and Restriction Removals

ADDED TO FORMULARY NOT ADDED TO FORMULARY (NON-FORMULARY) PA/QL REQUIREMENT REMOVED OR MODIFIED

calcipotriene ointment (Calcitrene) alcaftadine (Lastacaft) adapalene/benzoyl peroxide (Epiduo) – PA criteria modified

risedronate (Atelvia) – QL aliskiren/amlodipine/HCTZ (Amturnide) clindamycin/tretinoin (Veltin, Ziana) – PA criteria modified

bromocriptine (Cycloset)

gabapentin – QL removed

buprenorphine patch (Butrans)

lovastatin – QL removed

carglumic acid (Carbaglu)

pravastatin – QL removed

clonidine XR (Nexiclon)

sapropterin (Kuvan) – SP requirement removed; PA required

clonidine SR (Kapvay)

simvastatin – QL removed

dextromethorphan/quinidine (Nuedexta)

tretinoin (Tretin-X) – PA criteria modified

drospirenone/ethinyl estradiol/folate (Safyral)

everolimus (Zortress)

glycopyrrolate (Cuvposa)

lurasidone (Latuda)

norethindrone/ethinyl estradiol/iron (LoLoestrin Fe)

saxagliptin/metformin (Kombiglyze XR) – PA

tesamorelin (Egrifta)

ulipristal (Ella)

Products Removed from Formulary or Newly Restricted

PRODUCT

CHANGE AND EFFECTIVE DATE

propoxyphene (Darvon, generics) and

Effective 1/17/2011, all propoxyphene-containing products were removed from the formulary and restricted. These products will be

propoxyphene/acetaminophen (Darvocet, generics) removed from the market by the FDA based on safety concerns.

pegfilgrastim (Neulasta)

Effective 2/1/2011, pegfilgrastim requires PA for all clinic-administered and home-administered doses.

Products Newly Available as Generics (brand becomes non-formulary when equivalent generic available)

PRODUCT

FORMULARY STATUS / NOTES

amlodipine/benazepril (Lotrel)

formulary; covered at 1st tier; all strengths are now available as generics

donepezil (Aricept)

formulary; covered at 1st tier; PA required

ergotamine/caffeine (Cafergot)

formulary; covered at 1st tier

phenelzine (Nardil)

formulary; covered at 1st tier

zafirlukast (Accolate)

non-formulary; covered at 3rd tier; PA required

PA = prior authorization required, QL = quantity limit, SP = specialty pharmaceutical, ST= step therapy required

Where to find information when you have questions

TOPIC

WHERE AVAILABLE

To check the formulary status or restriction status of a drug

unityhealth.com by selecting Members and then Drug Formulary under Quick Links

To obtain a copy of Unity’s Prescription Drug Formulary

unityhealth.com by selecting Members and then Drug Formulary under Quick Links

To appeal a Prior Authorization denial Unity Customer Service – 800-362-3310

To speak to a clinical pharmacist about why a Prior Authorization Request was denied Unity Clinical Pharmacy Program – 888-450-4884

To check if a clinic-administered medication requires prior authorization

Unity Clinical Pharmacy Program – 888-450-4884 or unityhealth.com by selecting Providers, then

Pharmacy Information and then Medication Prior Authorization

or unityhealth.com by selecting Providers, Practitioner Resources and then Prior Authorization

Early refills, vacation supplies, emergency supplies, new member supply,

unityhealth.com by selecting Members, then Using Your Pharmacy Benefits and

reimbursement of medications purchased out-of-pocket

then Understanding Your Pharmacy Benefits

To enroll in the RX90 Extended Supply program or the UW Health Pharmacy – 866-894-3784

Specialty Pharmaceuticals program Hometown Pharmacy – 888-846-1819

To inquire about the RX90 Extended Supply program or the

unityhealth.com by selecting Members, then Using Your Pharmacy Benefits and then

Specialty Pharmaceuticals program

Understanding Your Pharmacy Benefits

Unity Continues to

Provide Top Notch Service

We want your experience with Unity to be the very best.

In order to provide you the best experience, Unity strives to:

Provide prompt and accurate service from knowledgeable,

local customer service representatives

Keep our promises and commitments to our customers

Exceed our customers’ expectations in everything we do

To help ensure these promises are met, Unity sets annual

customer relations goals and monitors these goals

throughout the year. Last year, on average, we achieved

the following results:

Answered your telephone calls within 14 seconds

Resolved over 95% of your telephone calls on the

same day

Processed your medical claims within 17 days

Processed your identification card requests within

three days

We are proud to provide you with the very best experience!

For more information about our goals for providing you

with excellent service, visit unityhealth.com and click

Members and then Unity’s Promise to Our Members.

1 8-ounce container fat-free

Greek yogurt (1 cup)

1/2 cup grated unpeeled English

(or hot house) cucumber, drained

and patted dry

2 tablespoons grated onion

(sweet preferred)

1 tablespoon snipped fresh dillweed

(optional)

HEALTHY RECIPE

Whether you serve this quick mixture as a dip, spread, or condiment, you will love having it in your recipe repertoire.

Garlicky Greek Yogurt Dip

In a medium bowl, stir together all of the ingredients.

Serve immediately or cover and refrigerate for up to 24 hours.

1 tablespoon fresh lemon juice

2 teaspoons chopped fresh mint (optional)

2 teaspoons honey

2 large garlic cloves, minced

1 teaspoon olive oil (extra-virgin preferred)

1/2 teaspoon dried

oregano, crumbled

1/8 teaspoon salt

Cook’s Tip: Greek yogurt is strained, making it richer and thicker than the yogurt you probably have been using.

Greek yogurt is now readily available in specialty food stores as well as natural food stores, high-end supermarkets,

and the health section of many other supermarkets.

Unity Health Service Staff Tip: You can purchase any low-fat plain yogurt and use a dish cloth (preferably a cheese

cloth type fabric) to act as a strainer. Pour the yogurt into the dish cloth center, gather up the sides and hang it above

a bowl for two hours or overnight. The liquid will drain out and you’ll be left with a thicker, creamier version of yogurt

which will work well for this recipe.

Serves: 10; 2 tablespoons per serving; Prep Time: 18 minutes

Nutrition Information Per Serving:

Calories Per Serving; Total Fat 0.5g; Saturated Fat 0.0; Trans Fat 0.0; Polyunsaturated Fat 0.0; Monounsaturated Fat

0.5g; Cholesterol 0.0mg; Sodium 38mg; Carbohydrates 3g; Fiber 0.0; Sugar 0.2g

This recipe is brought to you by the American Heart Association’s Patient Education program. ©2008.

Look for other delicious recipes in American Heart Association cookbooks, available from booksellers everywhere

and at heart.org/recipes.

I S S U E 1 / 2 0 1 1 7


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840 Carolina Street

Sauk City, WI 53583-1374

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PERMIT NO. 406

Complaints and Grievance Resolution

We are dedicated to providing quality service to our

members. Our goal is to continuously improve the care

and service members receive, so we look to you for

comments and suggestions. There may be a time when

you have a concern. As a member, you have the right to

voice a complaint or appeal a decision made by Unity

and to receive a prompt and fair review.

Unity has developed a comprehensive process for

handling member complaints. If you have a complaint

you would like Unity to address, you may contact Unity

Customer Service through Ask an Expert within

MyUnity at unityhealth.com or at 800-362-3310 and

select option 4. Unity’s Customer Service Representatives

are dedicated to resolving member complaints in a

timely fashion. If Unity Customer Service is unable to

resolve your complaint, the member advocate will assist.

Unity’s grievance process includes a comprehensive

review of your grievance by the member advocate as

well as review by qualified medical personnel and/or the

Reconsideration Committee when needed.

The Reconsideration Committee was established to

assure you receive all the benefits permitted or allowed

by your contract as well as a fair and impartial hearing

of your grievance. This Committee also provides you

the opportunity to share information concerning your

grievance in person.

In some cases, you may have the right to have your

grievance reviewed by a certified Independent Review

Organization (IRO). If you are notified that your

grievance qualifies for an IRO, you must send your

request to Unity within four months of the date Unity

denied the grievance and inform us of the IRO you wish

to use.

Unity will provide language interpretation for

members who are unable by reason of language barrier

to file a complaint or grievance. You may contact

Unity Customer Service through Ask an Expert within

MyUnity at unityhealth.com or at 800-362-3310 and

press option 4 for assistance regarding interpretation

services.

For more information about certified IROs,

please contact the State of Wisconsin Office of the

Commissioner of Insurance or visit their website at

www.oci.wi.gov/iroscert.htm.

If you would like more specific information

about Unity’s appeal process, please visit

unityhealth.com and click Members, Using

Your Plan, Claims Process and then Appeals.

Congratulations to Our Fill It In and Win Program Winners

We are proud to announce the winners of the

Winter 2011 Unity Fill It In and Win immunization

drawing. The prizes included a $150 gift card to

Dick’s Sporting Goods and six other cash prizes.

Congratulations to our winners!

Grand Prize Winner –

$150 Gift Card to Dick’s Sporting Goods

Charles K. of Madison, WI

First Prize Winner – $100

Jory T. of Madison, WI

Two Second Prize Winners – $50 each

Kaitlyn M. of Watertown, WI

Nicholai S-B of Madison, WI

Three Third Prize Winners – $25 each

Vanessa M of Madison, WI

Alaina B. of Madison, WI

David B. of Verona, WI

About the Fill It In and Win! Program

Unity offers a Fill It In and Win prize drawing for

fully immunized 24-month-old kids twice per year.

Entry cards are mailed to homes when kids turn

19 months of age. The child will be entered into the

drawing for prizes in either the summer or winter

semi-annual drawing depending on when the card

is returned and the last date of the completed

immunizations.

For more information about the program, including

a printable copy of the program entry card, please

visit unityhealth.com and click Health & Wellness,

then Preventive Health, then Immunizations, and then

Fill It In and Win.

8

I S S U E 1 / 2 0 1 1

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