In general, you need to receive care inside your designated network to have coverage for your medical care through the HSHS Healthy Plan. Your network is determined by your home ZIP code.
You are inside the HSHS/Prevea360 network service area if your listed residence is in one of the designated ZIP codes. If your address is in the HSHS/Prevea360 network service area, you'll see providers in the Exclusive Provider Organization (EPO). In most cases, this covers service received only from HSHS/Prevea 360 network providers, which includes PCIN providers. This means if you receive care outside the network, you will most likely be responsible for the full cost of care.
If your ZIP code is not listed—and you live in Wisconsin—your network providers are also the Exclusive Provider Organization (EPO). Since you live outside of the service area, you can also use the First Health network. In most cases, the plan covers services received from only HSHS/Prevea 360 network providers, which includes PCIN providers and the First Health network.
You and your dependents are still able to receive care from an HSHS/Prevea 360 network provider as well as a PCIN provider. Your insurance member identification card will include both Prevea360 and First Health logos on the front.
You don't need a referral or prior authorization for emergency services — no matter where you travel. We will cover emergency services while you're out of the network service area, subject to policy copays, co-insurance and deductibles.
If you need emergency care outside the service area and are unable to get to a plan provider, go to the nearest urgent care or emergency center. It is important to notify Dean as soon as possible by calling the Customer Care Center at 1-888-895-1188.
All follow-up care should be done by a plan provider. If you are out of the area and unable to see a plan provider, call your primary care practitioner for a referral to an out-of-area provider. These services require approval by Dean Health Plan.
To reduce the chance of being billed for maximum allowable fee charges, you can use our complementary network provider network by accessing First Health.
HSHS is committed to helping your dependent get the health care coverage they need when they need it. Students who attend college outside of the area and children living in communities outside the Dean Health Plan service area are common examples of out-of-area dependents. Designated out-of-area dependents have additional providers available to them.
While a referral isn't needed for your out-of-area dependent to access First Health providers, remember that there may be services that require a prior authorization.
To receive this benefit, you or your out-of-area dependent must contact Customer Service before receiving any services:
If your dependent needs urgent or emergency care outside the service area and is unable to get to a plan provider or First Health, he or she should go to the nearest urgent care or emergency center for treatment. It is important to notify Dean as soon as possible by calling the Customer Care Center at 1-888-895-1188.