Who is eligible for Senior Preferred?
In order to be eligible for ProHealth Senior Preferred, you need to live in Waukesha County, Wisconsin. Also, in order to be eligible for any Medicare Advantage program, including Senior Preferred, you must be eligible for Medicare Part A and enrolled in Medicare Part B.
What premium payment options do I have?
You can choose from three premium payment options including coupon book, automatic withdrawal from your bank account or automatic withholding from your Social Security or Railroad Retirement Board check. Please note, we are not able to accept cash payments.
What if I have a question regarding a claim?
Is my routine doctor's visit paid every 12 months or calendar year?
Senior Preferred members are eligible for one routine physical and vision exam every 12 months. If you have questions about the timing of your visit(s), please don't hesitate to contact Customer Service.
How do I find a doctor?
How can I change my personal physician?
Am I covered when I am out of the service area?
Emergency or urgently needed care is covered anywhere in the world when you are traveling outside the service area. For medications (Part D drugs), prescriptions must be obtained within the United States.
How do I get a new ID card?
What rights and responsibilities do the Plan and I have upon disenrollment?
Please refer to your Evidence of Coverage to learn more about your rights and responsibilities. You can search for your plan documents, including the Evidence of Coverage, on this web page.
What is the difference between a General Authorization and a Durable Power of Attorney?
A Durable Power of Attorney (DPOA) allows one individual to make decisions on behalf of another. A DPOA remains effective for life unless it is revoked. There are two types of DPOA, one that applies to financial decisions and one that applies to health care decisions. A General Authorization allows you to designate another individual to discuss your personal information. It does not allow the person to make decisions on your behalf. A General Authorization remains in effect for two years unless revoked. You may also provide verbal consent to allow us to talk with another person you designate as your representative. However, your verbal consent is only valid on the day that it is given. If you would like to have another person continue to assist you, please submit a General Authorization Form to us.
Part D Prescription Drug Questions
What if I already have prescription drug coverage through Senior Care, Veterans Administration or a Retiree Plan?
Anyone with current drug coverage through Senior Care, Veterans Administration (VA), Tricare, or a Retiree Plan can choose a Medicare Advantage plan without Part D drug coverage and avoid penalties if their drug coverage is at least as good or better than Medicare Part D coverage. Please contact Customer Service for further details.
Are over-the-counter drugs covered?
Over-the-counter drugs are those that can be purchased without a prescription. Even with a prescription from your doctor, these drugs are not eligible for coverage with Senior Preferred. In addition, the cost of over-the-counter drugs is not applied to your yearly out-of-pocket maximums.
What is my prescription coverage if I am out of the service area?
Senior Preferred Part D drug coverage is processed through a pharmacy benefit manager. The Senior Preferred pharmacy benefit manager has contracts with over 55,000 pharmacies nationwide, which exceeds the Medicare access guidelines. Therefore, you will have coverage for prescription drugs outside of our service area as long as you choose a pharmacy contracted through pharmacy benefit manager. You can contact us to locate a pharmacy or use our online Provider and Pharmacy Directory (select the Pharmacy button).
What are my prescription copays and coinsurance?
The amount you pay for your medication(s) can be located in your Plan's Summary of Benefits document.
What is a generic equivalent?
A medication that contains identical amounts of the same active ingredient in the same dosage form and route of administration that is expected to have the same clinical effects and safety profile as another product as designated by the United States Federal Food and Drug Administration (FDA).
Are generic drugs safe and effective?
Yes, according to the Federal Food and Drug Administration (FDA) generic drugs are safe and effective. Generic medications must meet the same standards for purity, strength, and quality as brand name drugs. They must be approved by the FDA before they can be sold to consumers. Generics may look different from the brand name medication in color, shape, or size as required by the Federal Food and Drug Administration (FDA).
What is the Prior Authorization medication List?
To promote the most appropriate utilization, certain medications require an approval of a prior authorization by our Pharmacy Department. Upon enrollment or upon request, the member will receive a list of prior authorized prescription drugs. These medications are also identified on the Formulary with a (PA) after the drug name. Prior authorization criteria is established by our Pharmacy and Therapeutics Committee with input from plan physicians and consideration of the current medical literature. If a medication is required that is not routinely covered, the provider may present medical evidence to obtain an individual patient exception by submitting an exception request for review.
What can I do if my prescription drug requires a Prior Authorization, or is not covered?
As a member of Senior Preferred, you may initiate an exception request process. For your convenience, we have prepared a form that you may complete and fax or mail to us. To complete the Drug exception request click here.
What is a mail service pharmacy?
A mail service pharmacy delivers medicines to your home through the mail. By using a mail service pharmacy you can get up to a 90-day supply of medication, often at a lower copayment. Mail service pharmacies deliver medicines in a confidential package. Many people prefer the convenience of this type of service. Senior Preferred members are not required to use a mail service pharmacy. However, if you are interested in using one, more details may be found here - Mail Service Pharmacy.
How do I request reimbursement for a prescription I paid for myself?
When purchasing prescription medications, you are encouraged to use your Senior Preferred ID card. If for some reason you are unable to utilize your pharmacy card, and are required by the pharmacy to pay for the medications, you may submit your itemized pharmacy receipt to us. Prescription medications purchased from a pharmacy will be reimbursed through our Pharmacy Benefits Management (PBM) at our current discount contracted rates. Any difference between the discount contracted rate and what the provider has billed will be your responsibility.
What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law that applies to both insurance companies and providers. HIPAA provides portability and continuity of health insurance coverage as well as protection of your personal health information.
What do I do if I believe that my privacy rights have been violated?
If you have questions or concerns about the way Senior Preferred has protected the privacy of your personal information, please contact the Privacy Specialist at (608) 881-8155.
This webpage was updated on October 1, 2018.