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Anthem Blue Cross :

PW_A116313

Other Forms and Information

This form can be used by all UC members to submit claims for non participating providers. 
This form is to be used by the Anthem Lumenos PPO with HRA plan members who are seeking reimbursement for services provided by United Behavioral Health. 
This form can be used by UC members to submit foreign claims. 
This form can be used by UC members to submit certification for an unmarried dependent child who is disabled. Completed forms should be faxed or mailed to UC Member Services at 818-234-2038 or P.O Box 60000, Los Angeles, CA 90060  
This form should be used by members who are in a course of treatment, or pregnant, whose physician does not participate in the Anthem Blue Cross network, or whose medication is not part of the Anthem Blue Cross formulary. 
The HIPAA privacy rules limits the use and disclosure of a members protected health information (PHI) without an authorization from the individual or their legal personal representative. This form will need to be filled out by the member to designate anyone other than a UC benefits representative to receive PHI. 
Attached is the EOB brochure which includes a sample EOB and how to locate information on it. 
Anthem Blue Cross has a formal process for reviewing member grievance and appeals. 
 
Express Scripts Member Claim Form - Express Scripts Members must submit the attached prescription drug claim form to get reimbursed on their prescription to the following address: Express Scripts, Inc., P.O. Box 66583, St. Louise, MO 63166-6583. 
Express Scripts Medicare Part D Member Claim Form - Express Scripts Medicare Part D Members must submit the attached Express Scripts Medicare Part D Prescription Drug Claim form to get reimbursed for their prescription to the following address: Express Scripts, Inc., P.O. Box66752, St. Louise, MO 63166-6752.  
Express Scripts Prior Authorization - Some drugs, and certain amounts of drugs, require an approval before they are eligible to be covered by your plan. This approval process is called prior authorization. Please click here to view list of drugs that require prior authorization. If your medication requires you to obtain the prior authorization you must log in as a member to print the prior authorization form. Please click here and select pharmacy prior authorization form. 

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.