Frequently asked questions (FAQ) in California

The only way you can have access to plan information from the online account is to ask the primary account holder, also known as subscriber, for access. Once the subscriber gives you access, you will be able to view plan level information (like Deductible) from the online account.

Once they’ve set up an account, they will be able to view, update and manage claims and benefit information as well as manage other features on your online account on your behalf.

Caregivers have access for one year. Each year access has to be set up again for security purposes. You can change access settings at anytime.

The only way a caregiver can get access to a member’s plan information is to ask the primary account holder, also known as subscriber, for access. Once the subscriber gives you caregiver access, you will be able to view, update and manage online account information on their behalf. You can also contact Customer Service using the number on the back of the member’s ID card for help.

If you are the health care power of attorney and need to access online account information for a member, you will need to contact Customer Service using the number on the back of the member’s ID card for help.

If you are a guardian caregiver and need to access online account information for an underage member, you will need to contact Customer Service using the number on the back of the member’s ID card for help.

It’s important to have what you need to use your health plan. You deserve simple, straight-forward plan details, no matter what language you speak.

• Just call the service number on your ID card.
• Customer Service will set up a conference call for you with an interpreter.
• He or she will help you understand your plan, and translate printed plan materials over the phone, if needed.
• This is a free service that’s available during business hours.
• Your native language or ethnic background does not impact getting quality service or coverage from us.
• For Speech or Hearing-Impaired Members, just call 711 for TTY/TDD services. A special operator will contact Anthem to help with your needs.

In order to access the myStrength website, you will need to have Internet Explorer 8 (IE8) or newer. If you have IE7 (or IE8 in compatibility mode for IE7), you can:

• Change/update your browser to IE8 or newer to navigate to and on the myStrength website.
  • Change your compatibility settings in IE8.
    In IE8, please click on the "Tools" menu and choose "Compatibility View Settings".
  • Please UNCHECK the selection for "Display all websites in Compatibility View" if it was checked (this setting must be unchecked in order for you to be able to view the myStrength page).
• If the above options do not work, please try accessing the myStrength website using Chrome as your browser.

Your household members may have trouble logging in when the member through their employer group has both Behavioral Health Resource and Employer Assistance Program (EAP). When members have both of these programs, household members should use the EAP website to access myStrength. For household members’ first visit to the myStrength site, s/he should call customer service at 800-865-1044 for assistance with the referral form to set up his/her access.

If you are logging onto the health plan’s website and don’t see the myStrength link on the homepage, please look on the middle of the page. You may need to scroll down to view the link.

Log in to find your claims. You'll see a status for each claim, saying what stage of the claims process it is in.

Please contact customer service by calling the telephone number on the back of your member identification card.

Customer service can also guide you through a variety of programs and services we offer to support breastfeeding mothers.

COBRA is a federal law that enables employees and their covered dependents to maintain their group health coverage for 18, 29 or 36 months after becoming ineligible for regular group coverage. The COBRA law does not apply to group health plans maintained by a small employer (normally fewer than 20 employees on a typical business day).

Once you're logged in, you can find a good amount of info on your claims or benefits by selecting the Claims or Benefits items in the menu. You can also find some basic info by looking on the back of your ID card.

If you don't find answers to your questions, please call Member Services at the number listed on your ID Card.

Generally, individuals become eligible to enroll in Medicare when they reach age 65, or are disabled and have been receiving Social Security Disability Income (SSDI) checks for 24 months, or have a diagnosis of either end-stage renal disease or ALS (Lou Gehrig's Disease).

While the law allows people to maintain their group health coverage and coordinate it with Medicare, anyone covered by a group plan who is planning on enrolling in Medicare should check their group plan's eligibility rules to find out their plan's rules regarding Medicare enrollment, and to determine which insurance is primary (pays first), and which is secondary. Watch the relevant dates carefully, and beware that eligible individuals only have 80 days to enroll in Medicare Part B after their group health benefits end, or face paying a higher Part B premium as penalty.

Yes. You get discounts through our SpecialOffers program - just for being a member. It's easy. Log in and visit our Discounts page.

You get discounts through our SpecialOffers program - just for being a member. It's easy. Log in and visit our Discounts page.

Consumer-driven health plan (CDHP) is a high-deductible plan that also includes a tax-free health savings account (HSA), health incentive account (HIA) or health reimbursement account (HRA). You may put tax-free money into your account, or your employer might put money in - sometimes as a reward for steps you've taken for better health, depending on your plan. Then you use that money for your share of care costs, like your deductible or coinsurance.

It’s called consumer-driven because it puts you in the driver’s seat of your health and health care spending. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.

Health Savings Account (HSA) plan is a high-dedutible plan that also includes a tax-free HSA. You can put tax-free money into it. Then use that money for your share of care costs, like your deductible or coinsurance. You can see all of the types of costs you can cover with money in your HSA. But remember that only cost your plan covers will go toward paying down your deductible.

It gives you the flexibility of a PPO - you can often go to doctors in and out of your network, though you’ll get better rates with in-network doctors. HSA plans tend to have lower monthly premiums than similar PPOs, and sometimes even HMOs.

It’s sometimes called a consumer-driven health plan (CDHP) because you’re in more control of your care spending at first. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.

You (or sometimes your employer) can put tax-free money into your health savings account (HSA). Then you use that money to pay for your share of care costs, like your deductible or coinsurance. Some people cover for all their care costs with their HSA dollars — since your checkups and other preventive care are already covered at 100%. Also, your plan comes with tools to help you find quality care at a lower cost.

If you still have money left in your account, it stays in there for next year and beyond. And you can also take it with you if you change health plans. View IRS rules on paying costs with money in your HSA.

A health incentive account (HIA) is a health account set up by your employer health plan. You earn dollars in your account when you take certain steps to improve your health. You use that money to pay for your share of care costs, like your deductible or coinsurance. If you don't use all the money, it stays in there next year as long as you're still at the same job.

Your employer puts money into your health incentive account (HIA) when you take certain steps to improve your health. You use that money to pay for your share of care costs, like your deductible or coinsurance. If you don't use all the money, it stays in there next year as long as you're still at the same job.

Yes. The three main types of FSAs are:

1. Health care FSA for qualified medical, dental, vision or other health care costs, including insurance deductibles, co-payments and co-insurance.
2. Dependent care FSA for child, elder or other dependent care.
3. Limited purpose FSA for qualified dental and vision care costs only when combined with a Health Savings Account (HSA) or a Health Reimbursement Account (HRA).

To be eligible for an FSA, your employer must offer it. You don't have to participate in your employer's health plan. You must elect to participate in the FSA during your employer's open enrollment.

For a Dependent Care Flexible Spending Account (DCA), you must have children under the age of 13 (if divorced, you must be the custodial parent) or you must claim an adult dependent on your tax return who’s physically or mentally unable to care for themselves.

Yes, you'll need to elect to participate in an FSA each plan year during your employer's open enrollment.

Qualified individuals must meet one of the following criteria: children under the age of 13 or any adult you can claim as a dependent on your tax return who is physically or mentally unable to care for themselves.

For more information, view IRS Publication 503 . 

To qualify for a DCA, you must be the custodial parent, even if you don't claim your child as a tax dependent.

For more information, view IRS Publication .

Typically anyone whose employer offers a DCA can participate. As a rule, your DCA can only cover expenses incurred during work hours. Ask your employer's benefits team to verify eligibility.

For more information, view IRS Publication .

To qualify, dependent care must be essential for you and a spouse (if applicable) to work, look for work or attend school full-time. Typical eligible expenses include:

• Before and after school care programs
• Preschool or nursery school
• Extended day programs and summer day camp
• Babysitter (in or out of your home)
• Nanny and au pair services
• Daycare and eldercare facilities

Expenses not related directly to care of the dependent (i.e. tuition, food, etc.) aren't eligible. Examples include:

• Educational expenses (summer school and tutoring)
• Tuition for kindergarten and above
• Overnight camp
• Field trip expenses and fees
• Housekeeping services
• Dependent care expenses incurred if your spouse doesn't work, unless your spouse is a full-time student or is disabled

The work related expense test is the standard the Internal Revenue Service uses to determine if expenses are work related for a DCA. An expense isn't considered work related just because you had it while you were working. Expenses are considered work related only if both of the following are true:

• They allow you (and your spouse if filing jointly) to work or look for work.
• They're for a qualifying person's care.

For more information, view IRS Publication 503 .

Contribution maximums are defined by the U.S. Department of the Treasury and the Internal Revenue Service and may increase for inflation annually. Visit www.irs.gov for the most current maximum amounts. 

Your spouse can also contribute up to the annual contribution maximum to their separate FSA. Visit www.irs.gov for the most current maximum amounts.

The entire amount you've elected to put into your FSA is available on day one of your plan, even if you're contributing a portion each month. You can use your funds by logging into your FSA administrator's website or by using your FSA debit card, if you've been provided one.

Your employer determines how your plan works. Employers can elect to offer a carryover. Carryover is a dollar amount (up to the Internal Revenue Service limit) of unused funds to use your new plan year. Any balance after that is forfeited to your employer. A grace period is extra days to incur new expenses and use funds after the plan year ends. Employers can't have both; they must only select one option. After that, any unused balance for the previous year goes back to your employer. Check your plan documents for what is allowed by your employer.

The run-out period is the time limit for submitting receipts for expenses incurred during the plan year. Check your plan documents for the run-out period allowed by your employer.

No.

No.

Internal Revenue Service guidelines state that you can't have both an HSA and a FSA. During open enrollment, if you elect an HSA plan, you may not re-enroll in an FSA. If your employer offers a Limited Purpose FSA, you may enroll in it.

Visit www.irs.gov for the most current maximum amounts.

No. The combined DCA contributions can't total more than the Internal Revenue Service maximum per plan year, per household.

Your DCA withholdings are reported on your W-2.

By logging onto your administrator's member portal.

By logging onto your administrator's member portal.

You must submit documentation. It can be an itemized receipt, invoice, explanation of benefits or other, but must include the patient name, name of the provider/pharmacy, the service/item purchased, date of the service/transaction and dollar amount.

When you use your FSA debit card, sometimes you may get an email or letter that asks you to "substantiate" a charge or claim. That just means supporting documentation is needed to make sure your FSA funds were used for eligible expenses.

You can submit a claim to your FSA that occurred anytime within the plan year up until the run-out period. Any claims submitted after the run-out date won't be approved.

You can only enroll and set how much you're putting into it during your employer's open enrollment period. However, if you have a change in your life such as getting married or divorced, a new child, moving, etc., contact your company's human resources department. You may qualify for a special enrollment period, and you'll be able to make changes to your FSA.

Your employer decides if your FSA has a run-out period. During a run-out period, you can submit a claim for expenses from the FSA plan year. Unused funds will be forfeited. Contact your employer for details.

Each FSA administrator is different. However, many offer an FSA debit card, a paper form for reimbursement, or a member portal for electronic reimbursement requests.

Reimbursements can be requested when a qualified expense is incurred during the plan year and before the end of the FSA run-out period (or grace period if applicable).

FSA plans typically include a time past the plan year for reimbursement requests for expenses during the plan year (known as a run-out period) or expenses up to the end of the extension (known as a grace period). Contact your employer for details.

The deadline for using DCA funds is the last day of the plan year.

Elections for DCA are made during open enrollment and can't be changed unless you experience a qualifying life event. Contact your employer for details.

Once we receive enrollment data from a state health insurance exchange marketplace, we process the information as quickly as possible and mail a payment letter to you as the customer. This payment letter serves as your receipt of enrollment. When everything works smoothly, this should only take about 10 days. However, sometimes processing the data can take time, especially if we need to go back and make sure any of the information is correct. There can also be issues with the initial application that keeps us from being able to process it, which will need to be corrected at your state's health insurance exchange marketplace. If you've been waiting longer than a couple of weeks to receive your letter, you will want to check on the status of your application - either with us or with the health insurance exchange marketplace. Click on the Contact Us tab to speak with an Anthem representative.

You should receive your ID card within about 10 days of paying your first premium. If you need care and you haven't gotten your ID card yet, ask your doctor to call us to confirm your benefits — and to make sure they're in your health plan network.

Yes, if you have individual or family coverage. You can make your initial premium payment securely through our website.

Call us at the number on the back of your Anthem ID card. There is a grace period to help you avoid having your coverage canceled. If you pass the grace period, your policy is canceled from the date you stopped paying. Any claims you had during that time will be denied and you will be responsibile for full payment of the health care services you received. You can re-enroll during the next yearly open enrollment.

Log in and go to your profile. You can change your preferences for how we communicate with you.

Once you receive your payment letter, it will share directions for you to pay the first month's premium. Payment of the first monthly premium is required to start the policy according to the details shared in your letter. You must take this step to activate your policy before your health insurance identification cards (ID cards) can be mailed.

If you're the primary person on your policy, you can view your info as well as some of your dependents'. When dependents are over 18, we have certain privacy rules in place that may restrict your access. But you can always change that by having that dependent log into their own profile and change who can view their info.

Typically, if you are the subscriber continuing with the same employer, and you move outside of the area we serve, if your place of employment is not located within the service area, your coverage and your dependents' coverage terminates as of your moving date. Potentially, your coverage may be picked up by the local Blue Plan (visit bcbs.com for details). If you are a covered dependent and you move out of the service area, you may still be eligible for coverage. Check your contract or Certificate for more information.

Check your contract or Certificate for more information. There are several possibilities:

• If you are eligible under a federal law known as COBRA, you may have an opportunity to remain covered under your employer's coverage for some period of time, provided you pay the full amount of your premium.
• Your employer may offer retiree coverage.
• You may have the opportunity to convert to an individual policy offered by Anthem.
• You may have the opportunity to continue coverage under your group coverage.

Contact your employer or Customer Care for more information and for eligibility guidelines that apply to you.

If you are the employee through whom you and your dependents are receiving benefits, you will need to check your contract or Certificate and talk to your employer for more information. If a covered dependent becomes disabled, coverage for that dependent may continue while your coverage is in force until the dependent is Medicare eligible. Contact your employer or Customer Care for more information and for eligibility guidelines that apply.

Typically, if your spouse was covered under your health benefit plan, he/she would cease being eligible for coverage through your contract upon the divorce. However, because of a federal law known as COBRA which might apply, your former spouse may be able to retain independent coverage under your employer's coverage for some period of time, provided he or she pays the full amount of their premium. He or she might also be able to obtain coverage through his/her employer, through other affiliations, or purchase individual coverage. He or she may also be eligible to convert to an individual policy of coverage offered by Anthem.

If new coverage is obtained within certain time frames, waiting periods and medical underwriting might not apply. Contact your employer, your Certificate or Customer Care for more information and for any guidelines that apply.

Check your contract or Certificate. If you are covered through an HMO benefit design, pre-existing conditions will be covered. In other types of product designs, it will depend on what your contract says, and whether or not you were covered by another contract prior to being covered through your current contract. Contact Customer Care for more information and for guidelines that apply to you.

Check with your employer, as well as your contract or Certificate for more information. There is a federal law known as COBRA which might apply. If COBRA applies to you, you have an opportunity to remain covered under your employer's coverage for some period of time, provided you pay the full amount of your premium. You may also be eligible to convert to an individual policy of coverage offered by Anthem. This is typically known as a "conversion privilege".

Note: If a service was authorized by us before termination, but is not rendered until after your coverage ends, Anthem is not responsible for paying benefits for such services.

A Consumer-Driven Health Plan (CDHP) is a high-deductible plan that also includes a tax-free Health Savings Account (HSA) or Health Reimbursement Account (HRA). Depending on your plan, you may put tax-free money into your account, or your employer might put money in, for example, as a reward for steps you've taken toward better health. Then, you use that money for your share of care costs, such as your deductible or coinsurance.

It's called "consumer-driven" because it puts you in the driver's seat of your health and health care spending. With your check-ups and preventive care likely covered at 100 percent by your plan, as well as tools to help you stay healthy and the ability to shop around for quality care at more reasonable costs, you might be able to use your CDHP to cover most if not all your health care costs.

You're eligible to have both only if the FSA has been defined as a Limited Purpose FSA, which may be limited to dental and/or vision services.

Your HSA is funded by your own pre-tax contributions, up to a certain annual limit. You may also contribute post-tax money to your HSA. Others (including your employer) may contribute to your account as well. The total of all contributions cannot exceed the maximums defined by the U.S. Department of the Treasury and the Internal Revenue Service.

The easiest way is through pre-tax payroll deductions, if allowed by your employer. However, you may also contribute directly to your HSA post-tax by following your bank's defined contribution process.

Contribution maximums are defined by the U.S. Department of the Treasury and the Internal Revenue Service and may increase for inflation annually. Go to www.irs.gov for the most current maximum amounts.

An HSA is a bank account you can use to pay for health expenses. You or your employer can put tax-free money into your HSA, and you'll use that money to pay for your share of care costs, like your deductible or coinsurance. If you don't use all the money in your HSA, it carries over into the next year and beyond. You can also take funds with you if you change health plans. Visit qme.anthem.com/ca for more information. 

Qualified medical expenses include medical, dental, vision and prescription expenses. Visit this website for more information: qme.anthem.com/ca 

Yes, FSA funds can be used for over-the-counter medicines without a prescription. Visit this website for more information: qme.anthem.com/ca 

Preapproval (also known as precertification, prior authorization, or preauthorization) is the process used to confirm if a proposed service or procedure is medically necessary. If you have a question, call the customer service number on your member ID card.

Not sure if a medication is covered? Search your plan's drug list or call the customer service number on your member ID card.

More information about health care costs and payments.

If you are pregnant and choose to breastfeed your newborn, we want to ensure you have the information, tools and support you need to be successful.

Many benefit plans offer pregnant women access to personal use, standard, double electric breast pumps through many of our contracted equipment suppliers at no cost to them. It is always important to check your member benefits to confirm coverage of a breast pump.

We want to make sure the process to access a breast pump is simple for you. If you are currently pregnant, we encourage you to talk with your physician and confirm your intention to breastfeed. Then, you may want to contact any of the following nationally contracted equipment providers to order your breast pump, or you may also call one of our many other contracted equipment providers.

Though there are many quality options available, you may have a particular brand in mind to meet your needs. Please be aware that the brands available from each equipment provider may vary. If you are not able to secure an order for the brand of your choice, please call the customer service number on the back of your member identification card to obtain assistance.

When contacting equipment providers please have your Anthem Member Identification number available, as well as your physician contact information. Some of the nationally contracted equipment (DME) providers are below:

Edge Park

www.edgepark.com 

800-321-0591 (phone)

330-425-4355 (fax)

Monday-Friday, 8 a.m. to 9 p.m.

Saturday, 9 a.m. to 3 p.m.

Byram

https://breastpumps.byramhealthcare.com 

877-773-1972 (phone)

800-521-6291 (fax)

Monday-Friday, 8 a.m. to 6 p.m.

Medline Industries, Inc.

https://insured.amedadirect.com 

877-791-0064 (phone)

337-628-2240 (fax)

It is always important to check your member benefits to confirm coverage of a breast pump. A breast pump is considered Durable Medical Equipment.

How is my HIA funded?

Your HIA is funded when you earn rewards for taking certain steps to improve your health. Check your Plan Summary for more information about earning rewards.

What type of services may I pay for with my HIA funds?

You can use the money in your HIA to pay for health care services covered by the Lumenos plan, such as doctor's office visits, prescription drugs, and lab tests. Check your Plan Summary for more information on covered services.

What is traditional health coverage?

Similar to a PPO or HMO plan, after you meet your deductible, you pay coinsurance (a percentage of the provider's charges) when you visit a network provider. You’ll pay more if you visit an out-of-network provider. Check your Plan Summary for more information on coinsurance amounts.

How do I check my health account balance?

It's easy. First register then log on at anthem.com. You can keep track of your account activity and balance and get details on your medical claims. You'll also receive a monthly statement with your account balance, account activity, medical and prescription claim history and important messages about how you may be able to improve your health or save money.

Can I roll over all the money in my HIA at the end of each plan year?

Yes. Whatever you don't spend on covered services will roll over to the next year, as long as you remain enrolled in the Lumenos HIA plan. You can use roll-over funds to help pay future out-of-pocket expenses.

If I leave this Lumenos plan, what happens to my HIA funds?

You cannot take your HIA funds with you if you leave the plan or your employer. The funds in your HIA stay with the health plan.

When your prescriber gives you a prescription for a drug, take it to a pharmacy in your network. Show your member ID card so the pharmacist can access your benefits. If you have medications that you take regularly, you may be able to have them conveniently and securely shipped to a location of your choice. 

By law you’re allowed to keep your group health benefits even when you’re eligible for Medicare. Some plans work well with Medicare benefits, or there may be reasons to keep your other coverage. Send us a quick message by logging in and going to your message center. Or you can call us at the number on your ID card.

Reminder: If your group benefits end and you’re eligible to enroll in Medicare Part B, do it within 80 days after your group health benefits end - or you could pay more.

Here's what it all means and how it works.

To see if the health care or service your doctor or other health care provider wants to give you is a “medical necessity,” Anthem looks at requests for authorization. Check your Evidence of Coverage or benefit booklet to know what makes something a “medical necessity” and when care requires this review.

A “medical necessity review” may be called utilization review (UR), utilization management (UM), or medical management. It is a review process that helps decide if a certain outpatient care, inpatient hospital stay, technology or procedure is medically needed.

Reviews can happen at different times including:

• When a service, treatment or procedure is asked for or planned ahead. We call this prospective or pre-service review.
• During the course of care. We call this inpatient or outpatient ongoing care review.
• After care or services have been given. We call this retrospective or post-service review.

With so many different things to consider, it may help to get a clear picture of what to expect and how the process works.

Timing matters.

We’re committed to deciding cases quickly. Here are types of reviews and time frames you can expect. (The maximum time allowed for a health plan to decide medical necessity once it gets the information needed.)

Non-urgent pre-service (before care):

• 5 business days for fully-insured and HMO/POS plans
• 15 calendar days for self-funded plans (unless otherwise stated in your Evidence of Coverage or benefit booklet)
• 72 hours for non-urgent prescription drug requests for fully-insured and HMO/POS plans

Urgent pre-service (before care):

• 72 hours
• 24 hours for urgent prescription drug requests for fully-insured and HMO/POS plans

Urgent inpatient or outpatient ongoing care (during care):

• 24 hours (in some cases) or no later than within 72 hours of getting a request

Retrospective/post-service (after care):

• 30 calendar days

What happens if there is a delay?

If we don’t have the information we need to make a decision, we try to get it from the doctor or other health care provider who requests the service or care.

We’ll write you and the requesting doctor or health care provider if there might be a delay because the information we need is not easy to get. This letter tells you what we need to make a decision. It also explains when to expect the decision once we get the information.

If we don’t get the information we need, we will send a final letter explaining that we are unable to approve access to this benefit because we don’t have enough information.

Professional reviewers decide

Qualified licensed health care professionals and doctors from Anthem Blue Cross and the medical group (or their peers) review requests and give an opinion specific to a medical condition, procedure and/or treatment under review. If the reviewer is unable to decide the medical necessity of a request, he or she may call the requesting doctor or other provider to discuss the case. In many cases, medical necessity can be determined after this call.

Decisions are based on what is right for each member for the type of care and service. Medically necessary review decisions made by Anthem Blue Cross are based on:

• Anthem’s medical policy criteria and guidelines (reviewed at least once a year and updated as standards and technology change).
• Nationally recognized clinical guidelines approved by a committee including practicing doctors and health care professionals not employed by Anthem Blue Cross.
• Your health benefits.

Employees, consultants or other providers are not rewarded or offered money or other incentives for denying care or a service, or for supporting decisions that result in using fewer services. Also, Anthem doesn’t make decisions about hiring, promoting or firing these individuals based on the idea or thought that they will deny benefits.

Medical necessity doesn’t mean payment or coverage

If we find services are medically necessary, it doesn’t mean the service is paid for or covered. Payment is based on the terms of your coverage at the time of service. There are some exclusions, limitations and other conditions that are part of your benefits. You will find them in your Evidence of Coverage or benefit booklet.

Payment of benefits could be limited for a number of reasons, such as:

• Information included with the claim differs from that given at time of review.
• The service performed is not covered.
• You’re not eligible for coverage when the service is given.

Decisions not to approve are put in writing

If we find the service is not a medical necessity, you and your doctor or health care provider requesting it will be sent written notice within two business days of the decision. This written notice has:

• A clear and simple explanation of the reason for the decision.
• The name of the criteria and/or guidelines used to make the decision and instructions for how to get a written copy.
• Information on how to appeal the decision and about your rights to an independent medical review.
• Specific parts of the contract that exclude coverage if the denial is based upon benefit coverage.

To see our guidelines

Anyone can see our medical necessity guidelines for specific services.

View our guidelines here. Scroll down and select Continue; you will see the Anthem Medical Policies & Clinical UM Guidelines Overview page.

• Select the Medical Policies or UM Guidelines option in the toolbar.
• Select the desired search option: Recent Updates or By Category.
• Select the desired Medical Policy or UM Guideline.

You may also call 1-800-794-0838 to request a free paper copy of the guidelines used to determine your case. These guidelines are used by Anthem Blue Cross to authorize, change or deny benefits for people with similar illnesses or conditions. Specific care and treatment benefits vary based on individual need and covered benefits.

Questions about utilization management? Call us.

To learn more about a UM medical decision, pre-authorization requests or the UR process, or if you have questions or issues, call our toll-free number: 1-800-274-7767, Monday through Friday (except holidays) from 8:00 a.m. to 5:00 p.m. Pacific Time.

If you call after hours or don’t reach someone during business hours, leave a confidential voice mail message with your name and phone number. We’ll return your call no later than the next business day, unless you request another time. Calls received after midnight will be returned the same business day.

You also can call Member Services at the number on your ID card to ask for an interpreter in your preferred language. They can read UM information in another language or help explain it in your preferred language free of charge.

If you have a hearing or speech loss, call 711 to use the National Relay Service or the number below for the California Relay Service. A special operator will contact Anthem to help with your needs.

1-800-855-7100 (English TTY/English voice)

To help ensure continuity/transition of care, we have in place a Transition Assistance Program for newly-covered members that may allow them, if eligible, to continue to see their treating doctor or health professional even though that provider is not part of their new health plan. This Transition Assistance Program is limited to situations where the member was receiving services for certain medical/behavioral conditions at the time their new coverage became effective. It allows in-network benefits for a defined period of time when the treating provider is not part of the Anthem Blue Cross participating provider network and there are clinical reasons preventing immediate transfer of care to another provider who is a participating provider. In addition, the non-participating provider and Anthem would need to agree on payment terms. Members who had the option to continue with their previous health plan or provider and instead chose to change health plans or providers are not eligible for the Transition Assistance Program.

Effective January 1, 2018 we expanded our Transition Assistance Program to include newly-covered members under an Individual health care service plan contract whose prior coverage was terminated when their health benefit plan was withdrawn from the market.

Continuity/transition of care may also be provided for members who experience a network disruption with their Primary Medical Group (PMG), Independent Physician Association (IPA), or hospital as a result of a closure or terminated contract with Anthem Blue Cross. Interested members may complete our Continuity/Transition of Care Request Form which provides valuable information needed by our staff in order to initiate the continuity/transition of care process.

We understand the importance of maintaining the patient/doctor relationship. You may request continuity/transition of care for completion of covered services by the non-participating provider for the conditions listed below. Please contact us using the toll-free number on your current ID card if you:

• Are pregnant.
• Are currently receiving ongoing medical or behavioral health care.
• Have a newborn child up to 36 months old who is receiving care.
• Have been diagnosed with a maternal mental health condition.
• Have a current authorization for health care services.
• Are otherwise concerned that this change will disrupt your care.

You can request continuity/transition of care or ask for further explanation of your rights to continued care. A Member Services representative can assist you with your request.

Eligibility for continuity/transition of care depends on factors outlined in your Evidence of Coverage or benefit booklet and Anthem Blue Cross’ Continuity of Care, Transition of Care Policy.

Access our Continuity/Transition of Care Request Form and Termination of Provider: Enrollee Notification Policy

Prior authorization is a required review of a service, treatment or admission for a benefit coverage determination, which is done before the service or treatment begins or admission date. Certain services require prior authorization in order for you to get benefits. Prior authorization includes a review to decide whether the service, treatment or admission is considered medically necessary or is experimental/investigational under the terms of your plan.

In general, the following treatments and services must be reviewed for prior authorization.  This is not a comprehensive list and coverage and/or prior authorization requirements may vary depending on your plan.

You can also check to see what services require prior authorization and how to request prior authorization review by calling Member Services at the number listed on the back of your member identification card.

Please check your plan for details about covered benefits, copayments, coinsurance, deductibles, limitations and exclusions or call member services for help with your questions.

• Inpatient Admissions:
  • Elective Admissions
  • Emergency Admissions
  • Inpatient Skilled Nursing Facility
  • Newborn Stays beyond Mother (NICU)
  • OB Related Medical Stay (OB complications, excludes childbirth)
  • Rehabilitation Facility Admissions
     
• Durable Medical Equipment 
  • (AAC) Devices/Speech Generating Devices (SGD) Augmentative and Alternative Communication
  • Automatic External Defibrillator
  • Bone Growth Stimulators
  • Electric Tumor Treatment Field (TTF)
  • Lower Limb Prosthesis
  • Myoelectric Upper Extremity Prosthetic Devices
  • Pneumatic Compression Devices for the Prevention of Deep Vein Thrombosis in the Home Setting
  • Pulse Generator System for Tympanic Treatment of Inner Ear Endolymphatic Fluid
  • Standing Frames
  • Transtympanic Micropressure

• Outpatient treatments, including certain ambulatory surgical procedures
  • Ablation of Solid Tumors Outside the Liver
  • Ablative Techniques as a Treatment for Barrett's Esophagus
  • Ablative Techniques Treating Primary and Metastatic Liver Malignancies
  • Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
  • Ambulance Services: Ground, Air and Water Ambulance Services (non-emergency)
  • Anesthesia Services for Gastrointestinal Endoscopic Procedures
  • Bariatric Surgical Procedures
  • Biofeedback and Neurofeedback
  • Blepharoplasty Procedures
  • Hearing Aids/Cochlear Implants
  • Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • Canaloplasty
  • Capsule Endoscopy
  • Cardiac Resynchronization Therapy (CRT)
  • Cardioverter-Defibrillators
  • CAR-T Therapy
  • Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement
  • Chemodenervation of extraocular muscle (for diagnosis of strabismus)
  • Chemodenervation of extremity and/or trunk muscles (e.g. for dystonia, cerebral palsy, multiple sclerosis)
  • Chemodenervation of internal anal sphincter (for diagnosis of anal fissure)
  • Chemodenervation of muscles innervated by facial nerve, unilateral (e.g. for blepharospasm, hemifacial spasm)
  • Chemodenervation of neck muscles (e.g. for spasmodic torticollis, spasmodic dysphonia)
  • Chin Implants
  • Contact Laser Vaporization of Prostate
  • Cosmetic and Reconstructive Procedures of the Head and Neck,  Trunk and Groin; and Skin Related
  • Cranial Remodeling Bands and Helmets (Cranial Orthotics)
  • Deep Brain Stimulation
  • Destruction by Neurolytic Agent
  • Drug-Eluting Devices for Maintaining  Sinus Ostial Patency
  • Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
  • Endoscopic Treatment of GERD, Dysphagia and Gastroparesis
  • Extracorporeal Shock Wave Therapy for Orthopedic Condition
  • Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
  • Facial Dermabrasion/Scar revision
  • Fetal Surgery for Prenatally Diagnosed Malformations
  • Focused Ultrasound Ablation of Uterine Leiomyomata
  • Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
  • Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
  • Gender Reassignment Surgery
  • Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • Gene Therapy for Ocular Conditions and Spinal Muscular Atrophy
  • Gynecomastia Repair
  • Hairplasty
  • High Intensity Focused Ultrasound for Oncologic Indications
  • Home Health, Home Infusion Therapy, Wound Care in the Home Setting
  • Hyperbaric Oxygen Therapy
  • Hysterectomy
  • Implantable Cardioverter-Defibrillator  (ICD)
  • Implantable Infusion Pumps
  • Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • Implanted Artificial Iris Devices
  • Inhaled Nitric Oxide
  • Insertion/Injection  of Prosthetic Material Collagen Implants
  • Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
  • Intracardiac Ischemia Monitoring
  • Intraocular Anterior Segment Aqueous Drainage Devices
  • Intraocular Telescope
  • Kyphoplasty Procedures
  • Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
  • Lysis of Epidural Adhesions
  • Magnetic Source Imaging and Magnetoencephalography
  • Mandibular/Maxillary  (Orthognathic) Surgery
  • Manipulation  Under Anesthesia
  • Maze Procedure
  • Meniscal Transplantation
  • Myomectomy
  • Nasal Implants
  • Nasal Surgery for the Treatment of Obstructive Sleep Apnea and/or Migraine Headaches (includes: Excision of Polyp(s), Turbinate(s), Ablation of Turbinate(s), Septoplasty, Repair of Vestibular Stenosis)
  • Neuroplasty
  • Neurostimulator Implantation
  • Occipital Nerve Stimulation
  • Open Sacroiliac Joint Fusion
  • Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • Panniculectomy/Abdominoplasty/Lipectomy/Diatasis Recti Repair
  • Partial Left Ventriculectomy
  • Patent Foramen Ovale and Left Atrial Appendage Closure for Stroke Prevention
  • Photocoagulation of Macular Drusen
  • Preimplantation Genetic Diagnosis Testing
  • Presbyopia and Astigmatism-Correcting Intraocular Lenses
  • Private Duty Nursing in the Home Setting
  • Real-Time Remote Heart Monitors
  • Removal of Lung
  • Rhinoplasty
  • Rosacea Treatment
  • Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
  • Sclerotherapy/Ablation of Varicose Veins
  • Somnoplasty
  • Specialty Pharmacy Medications – non-oncologic
  • Stereotactic Radiofrequency Pallidotomy
  • Subtalar Arthroereisis
  • Surgical Treatment of Migraine Headaches
  • Surgical Treatment of Migraine Headaches
  • Total Hip Arthroplasty (Elective)
  • Total Knee Arthroplasty (Elective)
  • Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
  • Transcatheter Heart Valve Procedures
  • Transtympanic Micropressure
  • Treatment of Hyperhidrosis
  • UPPP (Uvulopalatopharyngoplasty)
  • Uterine Fibroid Ablation - Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
  • Uterine Fibroid Embolization
  • UPPP (Uvulopalatopharyngoplasty)
  • Vagus Nerve Stimulation
  • Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
  • Virtual Colonoscopy
  • Viscocanalostomy
     
• Human Organ and Bone Marrow/Stem Cell Transplants
  • Donor Leukocyte Infusion
  • Donor Lymphocyte Infusion for Hematologic Malignancies  after Allogeneic Hematopoietic Progenitor Cell Transplantation
  • Heart Transplant
  • Kidney Transplant
  • Liver Transplant
  • Lung or Double Lung Transplant
  • Multi-visceral Transplant
  • Pancreas Transplant
  • Simultaneous Pancreas/Kidney
  • Small Bowel Transplant
  • Stem Cell/Bone Marrow Transplant (with or without myeloablative therapy)
  • Uterine Transplant
     
• Laboratory
  • Advanced Lipoprotein Testing
  • Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
  • Lab Testing to Aid in Diagnosis of Heart Transplant Rejection
  • Multi-biomarker  Disease Activity (MBDA) blood tests
  • Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
  • Rupture of Membranes Testing in Pregnancy
  • Serological Antibody Testing for Helicobacter Pylori
  • Vitamin-D deficiency in average risk individuals
     
• Mental Health/Substance Abuse (MHSA):
  • Applied Behavioral Analysis (ABA) - Not all plans include benefits for ABA/Adaptive Behavioral Treatment; contact Customer Service to determine if this is included as a benefit under the member’s plan and to confirm precertification requirements
  • Facility Based Care – Acute Inpatient Admissions, Partial Hospitalization, Intensive Outpatient Therapy (This includes Residential Treatment Centers, however, not all plans include Residential Treatment Center benefits; contact Customer service to determine if this is included as a benefit under your plan and to confirm precertification requirements
     
• AIM Specialty Health Programs (applies only to groups with the AIM Specialty Health Program) (https://aimspecialtyhealth.com/guidelines/185/index.html)
  • Cardiology
  • Genetic Testing
  • Musculoskeletal
  • Radiation Oncology
  • Radiology
  • Sleep Disorder Management
  • Specialty Pharmacy Medications - oncologic
  • Surgical GI
  • Surgical Site of Care

Consumer-driven health plan (CDHP) is a high-deductible plan that also includes a tax-free health savings account (HSA), health incentive account (HIA) or health reimbursement account (HRA). You may put tax-free money into your account, or your employer might put money in - sometimes as a reward for steps you’ve taken for better health, depending on your plan. Then you use that money for your share of care costs, like your deductible or coinsurance.

It’s called consumer-driven because it puts you in the driver’s seat of your health and health care spending. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.

Health Savings Account (HSA) plan is a high-deductible plan that also includes a tax-free HSA. You can put tax-free money into it. Then use that money for your share of care costs, like your deductible or coinsurance. You can see all of the types of costs you can cover with money in your HSA. But remember that only cost your plan covers will go toward paying down your deductible.

It gives you the flexibility of a PPO - you can often go to doctors in and out of your network, though you’ll get better rates with in-network doctors. HSA plans tend to have lower monthly premiums than similar PPOs, and sometimes even HMOs.

It’s sometimes called a consumer-driven health plan (CDHP) because you’re in more control of your care spending at first. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.

You (or sometimes your employer) can put tax-free money into your health savings account (HSA). Then you use that money to pay for your share of care costs, like your deductible or coinsurance. Some people cover for all their care costs with their HSA dollars - since your checkups and other preventive care are already covered at 100%. Also, your plan comes with tools to help you find quality care at a lower cost.

If you still have money left in your account, it stays in there for next year and beyond. And you can also take it with you if you change health plans. View IRS rules on paying costs with money in your HSA.

A health incentive account (HIA) is a health account set up by your employer health plan. You earn dollars in your account when you take certain steps to improve your health. You use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year as long as you’re still at the same job.

Your employer puts money into your health incentive account (HIA) when you take certain steps to improve your health. You use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year as long as you’re still at the same job.

Yes. The three main types of FSAs are:

1. Health care FSA for qualified medical, dental, vision or other health care costs, including insurance deductibles, co-payments, and co-insurance.
2. Dependent care FSA for child, elder or other dependent care.
3. Limited purpose FSA for qualified dental and vision care costs only when combined with a Health Savings Account (HSA) or a Health Reimbursement Account (HRA).

To be eligible for an FSA, your employer must offer it. You don’t have to participate in your employer’s health plan. You must elect to participate in the FSA during your employer's open enrollment.

For a Dependent Care Flexible Spending Account (DCA), you must have children under the age of 13 (if divorced, you must be the custodial parent) or you must claim an adult dependent on your tax return who’s physically or mentally unable to care for themselves.

Yes, you’ll need to elect to participate in an FSA each plan year during your employer's open enrollment.

Qualified individuals must meet one of the following criteria: children under the age of 13 or any adult you can claim as a dependent on your tax return who is physically or mentally unable to care for themselves.

For more information, view IRS Publication 503.

To qualify for a DCA, you must be the custodial parent, even if you don’t claim your child as a tax dependent.

For more information, view IRS Publication.

Typically, anyone whose employer offers a DCA can participate. As a rule, your DCA can only cover expenses incurred during work hours. Ask your employer’s benefits team to verify eligibility.

For more information, view IRS Publication.

To qualify, dependent care must be essential for you and a spouse (if applicable) to work, look for work or attend school full-time. Typical eligible expenses include:

• Before and after school care programs
• Preschool or nursery school
• Extended day programs and summer day camp
• Babysitter (in or out of your home)
• Nanny and au pair services
• Daycare and eldercare facilities

Expenses not related directly to care of the dependent (i.e., tuition, food, etc.) aren’t eligible. Examples include:

• Educational expenses (summer school and tutoring)
• Tuition for kindergarten and above
• Overnight camp
• Field trip expenses and fees
• Housekeeping services
• Dependent care expenses incurred if your spouse doesn’t work, unless your spouse is a full-time student or is disabled

The work-related expense test is the standard the Internal Revenue Service uses to determine if expenses are work related for a DCA. An expense isn’t considered work related just because you had it while you were working. Expenses are considered work related only if both of the following are true:

• They allow you (and your spouse if filing jointly) to work or look for work.
• They’re for a qualifying person’s care.

For more information, view IRS Publication 503.

Contribution maximums are defined by the U.S. Department of the Treasury and the Internal Revenue Service and may increase for inflation annually. Visit www.irs.gov for the most current maximum amounts.

Your spouse can also contribute up to the annual contribution maximum to their separate FSA. Visit www.irs.gov for the most current maximum amounts.

The entire amount you’ve elected to put into your FSA is available on day one of your plan, even if you’re contributing a portion each month. You can use your funds by logging into your FSA administrator’s website or by using your FSA debit card, if you’ve been provided one.

Your employer determines how your plan works. Employers can elect to offer a carryover. Carryover is a dollar amount (up to the Internal Revenue Service limit) of unused funds to use your new plan year. Any balance after that is forfeited to your employer. A grace period is extra days to incur new expenses and use funds after the plan year ends. Employers can’t have both; they must only select one option. After that, any unused balance for the previous year goes back to your employer. Check your plan documents for what is allowed by your employer.

The run-out period is the time limit for submitting receipts for expenses incurred during the plan year. Check your plan documents for the run-out period allowed by your employer.

No.

No.

Internal Revenue Service guidelines state that you can’t have both an HSA and a FSA. During open enrollment, if you elect an HSA plan, you may not re-enroll in an FSA. If your employer offers a Limited Purpose FSA, you may enroll in it.

Visit www.irs.gov for the most current maximum amounts.

No. The combined DCA contributions can’t total more than the Internal Revenue Service maximum per plan year, per household.

Your DCA withholdings are reported on your W-2.

By logging onto your administrator’s member portal.

By logging onto your administrator’s member portal.

You must submit documentation. It can be an itemized receipt, invoice, explanation of benefits or other, but must include the patient’s name, name of the provider/pharmacy, the service/item purchased, date of the service/transaction and dollar amount.

When you use your FSA debit card, sometimes you may get an email or letter that asks you to “substantiate” a charge or claim. That just means supporting documentation is needed to make sure your FSA funds were used for eligible expenses.

You can submit a claim to your FSA that occurred anytime within the plan year up until the run-out period. Any claims submitted after the run-out date won’t be approved.

You can only enroll and set how much you’re putting into it during your employer’s open enrollment period. However, if you have a change in your life such as getting married or divorced, a new child, moving, etc., contact your company’s human resources department. You may qualify for a special enrollment period and you’ll be able to make changes to your FSA.

Your employer decides if your FSA has a run-out period. During a run-out period, you can submit a claim for expenses from the FSA plan year. Unused funds will be forfeited. Contact your employer for details.

Each FSA administrator is different, however, many offer an FSA debit card, a paper form for reimbursement or a member portal for electronic reimbursement requests.

Reimbursements can be requested when a qualified expense is incurred during the plan year and before the end of the FSA run-out period (or grace period if applicable).

FSA plans typically include a time past the plan year for reimbursement requests for expenses during the plan year (known as a run-out period) or expenses up to the end of the extension (known as a grace period). Contact your employer for details.

The deadline for using DCA funds is the last day of the plan year.

Elections for DCA are made during open enrollment and can’t be changed unless you experience a qualifying life event. Contact your employer for details.

Once we receive enrollment data from a state health insurance exchange marketplace, we process the information as quickly as possible and mail a payment letter to you as the customer. This payment letter serves as your receipt of enrollment. When everything works smoothly, this should only take about 10 days. However, sometimes processing the data can take time, especially if we need to go back and make sure any of the information is correct. There can also be issues with the initial application that keeps us from being able to process it, which will need to be corrected at your state’s health insurance exchange marketplace. If you’ve been waiting longer than a couple of weeks to receive your letter, you will want to check on the status of your application - either with us or with the health insurance exchange marketplace. Click on the Contact Us tab to speak with an Anthem representative.

You should receive your ID card within about 10 days of paying your first premium. If you need care and you haven’t gotten your ID card yet, ask your doctor to call us to confirm your benefits -and to make sure they’re in your health plan network.

Yes, if you have individal or family coverage. You can make your initial premium payment securely through our website.

Call us at the number on the back of your Anthem ID card. There is a grace period to help you avoid having your coverage canceled. If you pass the grace period, your policy is canceled from the date you stopped paying. Any claims you had during that time will be denied and you will be responsible for full payment of the health care services you received. You can re-enroll during the next yearly open enrollment.

Log in and go to your profile. You can change your preferences for how we communicate with you.

Once you receive your payment letter, it will share directions for you to pay the first month’s premium. Payment of the first monthly premium is required to start the policy according to the details shared in your letter. You must take this step to activate your policy before your health insurance identification cards (ID cards) can be mailed.

If you’re the primary person on your policy, you can view your info as well as some of your dependents’. When dependents are over 18, we have certain privacy rules in place that may restrict your access. But you can always change that by having that dependent log into their own profile and change who can view their info.

A Consumer-Driven Health Plan (CDHP) is a high-deductible plan that also includes a tax-free Health Savings Account (HSA) or Health Reimbursement Account (HRA). Depending on your plan, you may put tax-free money into your account, or your employer might put money in, for example, as a reward for steps you’ve taken toward better health. Then, you use that money for your share of care costs, such as your deductible or coinsurance.

It’s called "consumer-driven" because it puts you in the driver’s seat of your health and health care spending. With your check-ups and preventive care likely covered at 100 percent by your plan, as well as tools to help you stay healthy and the ability to shop around for quality care at more reasonable costs, you might be able to use your CDHP to cover most if not all your health care costs.

Qualified medical expenses include medical, dental, vision and prescription expenses. Visit this website for more information:
 

qme.anthem.com/ca 

Yes, FSA funds can be used for over-the-counter medicines without a prescription. Visit this website for more information:
 

qme.anthem.com/ca 

Log in and send us a message through your Message Center.

You can review anthem.com/ca/dmhc to view, download, save, and print a copy of the DMHC regulatory mandated notices for Provider Timely Access and Grievance & Appeal regulatory notices.

You can review anthem.com/ca/cdi to view, download, save, and print a copy of the California Department of Insurance (CDI) inserts for Provider Timely Access and Grievance & Appeal regulatory notices.

To report issues with the listings in our Provider Directory, you can:

• call the Member Services phone number on the back of your ID card.
• send an email to ProviderDirectoryDiscrepancy@Anthem.com.
• call us at 1-844-839-4049.

Check your contract or Certificate for details. In most contracts, newborns are covered for their first 31 days of life automatically. Typically, you must enroll your newborn within 31 days from the date of the child's birth to continue coverage without interruption beyond the 31st day. Unless your contract or Certificate states otherwise, a newborn child of a dependent son or daughter does not qualify as a dependent under your coverage.

Check your contract or Certificate for details. In most contracts, adopted children are automatically covered for 31 days from the date of placement or adoption, whichever is earlier. Typically, you must enroll your adopted child within 31 days from the date of the child's placement with you or date of adoption, whichever is earlier to continue coverage without interruption beyond the 31st day. Unless your contract or Certificate states otherwise, an adopted child of a dependent son or daughter does not qualify as a dependent under your coverage.

Check your contract or Certificate. Typically, you need to contact us directly, or via your group if applicable, within 31 days of the event giving rise to the change. Requests for changes in eligibility need to be in writing.

Call Customer Support during normal business hours and request a Change of Eligibility Form. Customer Support numbers can be found on your insurance ID card and are specific to your account and plan.

Note that at any time we discover a person's ineligibility, we may cancel their coverage immediately, and recover from you the costs of any benefits paid on behalf of such person during the period of ineligibility.

Check your contract or Certificate. If a court order requires that you provide coverage for a child who is out-of-state, you must notify us of the court order within 31 days of its receipt, in order for coverage to be effective.

If you are covered through an HMO benefit design and your child is going to college outside of our service area, there may be special circumstances under which your child may be eligible for coverage other than emergency or urgent care benefits. If you are covered through a benefit design other than an HMO product, benefits may be covered for your child who is outside of our service area.

Children inside the service area are typically eligible for coverage, provided they meet the definition of "dependent" under your contract or Certificate. Contact Customer Service for more information and for eligibility guidelines that apply.

For plan years beginning on or after September 23, 2010, it has been our policy that children can remain on their parent's health plan until the end of the month they turn 26. Some self-insured plans or state mandates require us to administer to a different time period or age.

We always recommend that you check your plan specifics. Additionally, a dependent is defined as a child of the subscriber or participant who is under the age of 26. Financial dependency on or residency with the subscriber or participant is not required. Additionally, there is no requirement to be unmarried, student, employed or any combination of these factors.

Plans are also required to provide access to coverage regardless of a dependent's eligibility for other coverage, except for grandfathered group plans prior to 2014. For these grandfathered plans, groups may choose to exclude coverage for children under a parent's policy if they are eligible for their own employer sponsored coverage. For states or plans that cover other children (i.e., step children, children of domestic partners, etc.), that definition will not change.

Check your contract or Certificate. Typically, eligibility will be continued past the standard age limits specified in your contract or Certificate only for those already enrolled, unmarried children who cannot work to support themselves due to certain mental or physical disabilities. These children must be allowed as federal tax exemptions for the subscriber or the subscriber's spouse.

Under many health benefit plans, the disability must have started prior to the end of the period for which they would have otherwise been eligible under your coverage. We must be notified of the disability within 31 days after the child would normally have become ineligible, and we have the right to determine whether the child's condition meets our criteria for being covered under the coverage beyond the normal end date.

From time to time you may be asked to submit proof of continued disability. Failure to provide that information could result in termination of the child's coverage.

Once you're logged in, you can quickly view your benefit or claim information for you and potentially for your dependents on the policy. Dependents who are 18 years or older can adjust their settings in their profile online at any time and may or may not allow you to view their information online. A dependent can be a spouse, partner or child who is covered on the primary health insurance policy.

Doctors, hospitals, facilities (such as labs) and other professionals who give health care services may have a contract with us. If they do, they're in our network - also called in-network providers. That means they've shown they provide quality care and they accept our payment rates when our members go to them for care. If they don't have a contract with us, they're outside of our network - or out of network providers.

Many of our networks are made up of providers who meet high quality standards. Network providers are responsible for getting any needed preauthorization (approval) of your care. They also file your claim for you and will seek payment from us for covered services. When you see network providers, you only have to pay the copays, deductibles and coinsurance required by hour health plan.
 

If you get treatment from a provider outside the network, you may be responsible for getting preauthorization for a proposed service. You could have to pay more for services done outside of your network. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.

If you have questions or to check if your treatment needs preauthorization call the Member Services number listed on the back of your ID card.

Yes, although it does not make the most of your benefits and may end up costing you more. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) to learn more.
 

NOTICE: There are hospitals, health care facilities, physicians or other health care providers who are not included in every plan network. Your financial responsibilities for payment of covered services may differ if you use a network provider or a non-network provider. Please refer to the online Find Care tool to determine if a particular provider is in the network or contact customer service for assistance.

You could ask your doctor to call us and apply to join the network. Until your doctor becomes a provider in the network, changing to a network doctor will help you pay less and make the most of your benefits.

A primary care physician (PCP) is your main doctor. Always try to go to your PCP first for health concerns or questions.

Your PCP coordinates any other care you need, such as a visit to a specialist or a hospital stay. You may need to contact your PCP to get an OK (prior authorization) before you get certain services.
 

Most PCPs are family or general practitioners, internists, or pediatricians. These types of doctors have gone to school to learn about all areas of health. That way, they can get a strong, overall picture of your health.
 

Not all health plans require you to have a PCP. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.

In emergencies, call 9-1-1 or go to the nearest hospital - you don’t need an OK from us or your PCP. But be careful not to use the emergency room unless it really is an emergency.
 

If it’s not an emergency, you can see a doctor right away online, using your phone or computer at livehealthonline.com. Depending on your plan, it’s likely about the same cost as your doctor.
 

You can also use our Find Care tool to look for an urgent care center - or a clinic in a retail shopping store. You can usually walk in without an appointment needed. And they can handle lots of urgent health issues like a flu or cold, allergies, prescribing medication, even small fractures and X-rays.

You may need to contact your Primary Care Physician (PCP) to get an OK (prior authorization) before you get certain services, including behavioral health services. Your PCP will work with you to decide if you need to see a specialist. If so, your PCP will refer you to a network specialist. If you have to refer yourself to a specialist, you can search for a network specialist in our online directory. Check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details.

If your primary doctor can't see you that day or the next, you should find an urgent care clinic nearby. Log in to find Urgent Care for a clinic in your plan.

More information on standard waiting times is available in our Timely Access to Care brochure.

It can take up to 10-15 business days to get an appointment, depending on the care you are looking for.  Review our Timely Access to Care brochure for standard appointment wait times by medical, dental, vision and behavior health.

Call them. They should always have someone available, or a recorded message to help you get the care you need.

Simply enter the number into the Find Care search bar and hit enter.

To report issues with the listings in our Provider Directory, you can:

• call the Member Services phone number on the back of your ID card.
• send an email to ProviderDirectoryDiscrepancy@Anthem.com.
• call us at 1-844-839-4049.

Get a full list of the types of doctors, hospitals and other health care providers. Log in to and choose Find Care.

Call 911 or go to the closest emergency room anytime you have a life-threatening emergency. If you’re not sure it’s an emergency, call your doctor’s office for advice.

A guide to whether it’s an emergency is if your symptoms are so severe that you believe not getting medical care right away could place your or someone else’s health (or the health of an unborn child) at risk OR cause major harm to a body function or part.

Examples of an emergency include, when someone:

• May die
• Has chest pains
• Cannot breathe or is choking
• Has passed out or is having a seizure
• Is sick from poisoning or a drug overdose
• Has a broken bone
• Is bleeding a lot
• Has been attacked
• Is about to deliver a baby
• Has a serious injury
• Has a severe burn
• Has a severe allergic reaction or has an animal bite
• Has trouble controlling behavior and without treatment is dangerous to self or others

If you feel you’re having an emergency, you don’t need an OK from us or your PCP to get care.

An urgent medical condition is not an emergency, but needs medical care within 24 to 48 hours.

Here are some examples of urgent medical conditions:

• Ear aches
• Fever
• Stomach pain
• Vomiting
• Minor burns
• Sprains

Yes. You are covered for emergency or urgent care even if you are outside of our service area. It's helpful if you find the hospital and urgent/walk-in center nearest your home and call to ask if they have a contract with your health plan. (Do this before an emergency or urgent situation arises.)

Go to the nearest health care facility. Call your doctor or us within 24 hours, or as soon as you can. When your care is done, you will need to pay the bill. (You may want to use a credit card. The credit card company will automatically transfer the foreign currency into American dollars for you.) Keep all your receipts.

When you get home, call us at the number on the back of your member ID card or stop by your employer's personnel office and ask for a claim form. Fill out the claim form and submit it with your receipts to our address on the form. (The amount submitted must be in American dollars). We will pay you back based on your health plan benefits.

Yes. For emergency care, you’re covered virtually anywhere you go. You have urgent care centers and walk-in clinics in your health plan network. Even if you’re away from home, you can see a doctor online anytime at LiveHealthOnline.com. Or call us at the number on your Anthem Blue Cross ID card for help.

Please contact customer service by calling the telephone number on the back of your member identification card.
 

Customer service can also guide you through a variety of programs and services we offer to support breastfeeding mothers.

It is always important to check your member benefits to confirm coverage of a breast pump. A breast pump is considered Durable Medical Equipment.

Certain health plans that were in effect prior to March 23, 2010, may be "grandfathered health plans" under the Patient Protection and Affordable Care Act. If your plan is grandfathered, then your plan will include some consumer protections from the Affordable Care Act, but may not include other protections that apply to non-grandfathered health plans. If your plan is a grandfathered health plan, notice indicating that fact will be contained in your Certificate Booklet or your group's summary plan description.

As a member, you have rights and responsibilities when receiving healthcare. As your healthcare partner, we want to make sure your rights are respected, while providing your health benefits. That means giving you access to our network of doctors and healthcare professionals, who help you make the best decisions for your health.
 

You have the right to:

• Speak freely and privately with your doctors and other healthcare professionals about healthcare options and treatment needed for your condition, no matter what the cost or whether it is covered under your plan.
• Work with your doctors and other healthcare professionals to make choices about your healthcare.
• Be treated with respect and dignity.
• Expect us to keep your personal health information private by following our privacy policies and state and Federal laws.
• Receive information you need to fully engage with your health plan and also share feedback. This includes:
  • Our company and services.
  • Our network of doctors and other healthcare professionals.
  • Your rights and responsibilities.
  • The way your health plan works.
• Make a complaint or file an appeal about:
  • Your health plan and any care you receive.
  • Any covered service or benefit decision that your health plan makes.
• Say no to care, for any condition, sickness, or disease without it having an effect on any care you may receive in the future. This includes asking your doctors and other healthcare professionals to tell you how that may affect your health now and in the future.
• Get the most up-to-date information from a doctor about the cause of your illness, your treatment, and what may result from it. You can ask for help if you do not understand this information.
   

You have the responsibility to:

• Read all information about your medical benefits under the plan and ask for help if you have questions.
• Follow all medical Plan rules and policies.
• Choose a Network primary care physician, also called a PCP, if your health plan requires it.
• Treat all healthcare professionals and staff with respect.
• Keep all scheduled appointments. Call your doctor’s office if you may be late or need to cancel.
• Understand your health challenges as well as you can, and work with your doctors and other healthcare professionals to create an agreed upon treatment plan.
• Inform your doctors and other healthcare professionals if you don’t understand the type of care and your actions that they’re recommending.
• Follow the treatment plan that you have agreed upon with your doctors and other healthcare professionals.
• Share the information needed with us, your doctors, and other healthcare professionals to help you get the best possible care. This may include information about other health insurance benefits you have in addition to your coverage with us.
• Inform Member Services if you have any changes to your name, address, or family members covered under your plan.

If you would like more information, have comments, or would like to contact us, please go to anthem.com/ca and select Contact Us. Or call the Member Services number on your ID card.
 

We are here to provide high-quality benefits and service to our members. Benefits and coverage for services given under the plan are overseen by your Certificate of Coverage, Member Handbook or Schedule of Benefits and not by this Member Rights and Responsibilities statement.
 

A copy of the Member Rights and Responsibilities statement can also be found on our website FAQs. To access, go to www.anthem.com/ca and select Member Support/Support/FAQs/Laws and Rights that Protect You. Then click on “What are my rights as a member”.

Effective Date: 5/2011; Revised 2013,2015,2021,2024; Reviewed annually with last review 4/2025

A00617MUMENABS

Please click here to select your State and review your Medical Policies.

Please go to anthem.com/ca/privacy for information about our policies and procedures for the collection, use and disclosure of your protected health information (PHI). This includes, but not limited to information about routine notification of privacy practices, use of authorization, your access to medical records, protection of verbal, written and electronic information, information for employers, and more.

Please follow these instructions to file an appeal, grievance or complaint.

Yes. The Food and Drug Administration (FDA) will not approve a generic drug unless it’s A-rated ("therapeutically equivalent"). It must be identical to the brand-name version — same active ingredients, dosage and strength and medical effect.

Depending on their plan design, members can help control the amount they pay for their prescriptions by requesting that their prescriber prescribe generic medications. Generic medications don't compromise the quality of your care.

Your prescriber and pharmacist are the best sources of information about generic medications. Simply ask one of them if your prescription can be filled with an equivalent generic medication.

If your current prescription medication is not a generic, call your prescriber and ask if it's appropriate for you to switch to a lower-cost generic drug. The decision is up to you and your prescriber.

You may request that your prescriber prescribe the brand-name drug even when a generic version is available. However, you may have to pay the difference in cost between the generic and brand-name drug, plus the co-payment.

Brand-name drugs are usually available from only one manufacturer and may have patent protection. When a drug company develops a new drug, they're the only ones allowed to make and sell it under their “brand name.” At some point, other companies are allowed to start making "generic" versions. Generic drugs are required by law to have the same active ingredients as their brand-name counterparts, but are normally only available after the patent expires on a brand-name drug. People using generic over brand-name medications can typically save money.

Some plans require you to use a generic version when there is one, or you may need to pay a higher copay or coinsurance. Check your plan details to see how your plan works.

A drug list/formulary is a list of prescription drugs that we cover. This list is made up of hundreds of brand-name and generic drugs approved by the U.S. Food and Drug Administration (FDA). We update the drug list/formulary several times a year. Our drug list/formulary decisions are based first on quality data, instead of cost.

Prescriptions for certain drugs (or the prescribed quantity of a drug) may require “prior authorization” from a health benefits plan before they can be filled. Some drugs require prior authorization because they may not be appropriate for every member or may cause side effects. Prior authorization helps promote appropriate utilization and enforcement guidelines for prescription drug coverage.
 

“Step therapy” involves prescribing medication only after a “first line” drug is tried. In instances in which one of these medications is not effective and/or appropriate for a particular member, the step therapy requirements allow the prescriber to then prescribe a different medication.

Most plans have different coverage levels for drugs based on whether they're generic or brand-name — or other factors. Those on higher "tiers" may require you to pay more in coinsurance.

Our medication list (sometimes called a formulary) allows you and your doctor to choose from a wide variety of prescription drugs.  Please talk with your doctor about prescribing a drug that is on the medication list.  If a drug is selected that is not on the medication list, you will be responsible for the full cost of the drug.  You can also talk to your doctor about making a request to CarelonRx for an exception review of a drug not on the medication list.

From your secure online account, select Prescriptions from the main navigation and then select Prescriptions Home. There you'll find links for the specialty pharmacy.

Normally, a generic drug can be introduced to the market only after the patent has expired on its brand-name counterpart and can be offered by more than one manufacturer. Using generic medications may save you money.

When your prescriber gives you a prescription for a drug, take it to a pharmacy in your network. Show your member ID card so the pharmacist can access your benefits. If you have medications that you take regularly, you may be able to have them conveniently and securely shipped to a location of your choice. 

Supported Mobile Operating Systems

• Mobile iOS 18 series
• Mobile iOS 17 series
• Mobile iOS 16 series
• Android 13, 14, 15

Supported Desktop Operating Systems

• Windows 10
• OS X 10
• Chrome OS
   

Web Browsers
 

We recommend that you always use the current version of your browser and have the latest security updates to make sure that our web pages display quickly. Members using an unsupported operating system or device will not be able to access our site unless they upgrade. Members may also get an alert suggesting they upgrade to a newer operating system for best results.

Please note we no longer support Internet Explorer 11.
 

Supported Desktop Browsers

• Google Chrome 98 & 99
• Microsoft Edge 98 & 99
• Safari 15 Series
• Mozilla Firefox 98
   

Supported Mobile Browsers

• Safari 14 & 15 series
• Chrome Mobile 98 & 99
• Samsung Browser 16 series
   

Supported Apple Devices

• iPhone 11
• iPhone 12 Pro Max
• iPhone XR
• iPhone 12
• iPhone 12 Pro
• iPhone 13 Pro Max
• iPhone 11 Pro Max
• iPhone 13 Pro
• iPhone 11 Pro 
   

Supported Non-Apple Devices

• Samsung Galaxy S21 Series
• Samsung Galaxy S10 Series
• Samsung Galaxy S20 Series
• Samsung Galaxy S9 Series
• Samsung Galaxy Note 20 Ultra
• Samsung Galaxy Note 9
• Samsung Galaxy Note 10+