Your Annual Notices

IMPORTANT INFORMATION: Coverage for care after a mastectomy

Breast reconstruction surgery benefits

• Reconstruction of the breast(s) that underwent a covered mastectomy.
• Surgery and reconstruction of the other breast to achieve a symmetrical appearance.
• Prostheses and treatment for physical complications related to all stages of a covered mastectomy, including lymphedema.

All applicable benefit provisions will apply, including existing deductibles, copayments and/or coinsurance. Call your Plan Administrator (Employer) at the number on your ID card for more information.

For additional information about the Women's Health and Cancer Rights Act, you can go to the United States Department of Labor website at: www.dol.gov/agencies/ebsa/laws-and-regulations/laws/whcra.

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For members in Connecticut

Explanation of Benefits (EOB)

After receiving medical care, you should receive an Explanation of Benefits (EOB) – a summary of coverage received. The EOB is not a bill, but a statement from us to help you understand the coverage you received.

The EOB shows:

• Total amounts charged for services/supplies received.
• The amount of the charges covered by your medical plan.
• The amount you are responsible for (if any).
• General information about your rights to an appeal and your rights regarding any action after the appeals process.

You have a choice about how you receive your EOB and where it goes. You can let us know:

• Not to send an EOB.
• To send an EOB by providing a mailing address.
• To send an EOB electronically. We will send you a notification by e-mail or other electronic means selected by you when the EOB is available to review.

Your choice for an alternate method of delivery or suppression of an EOB must be submitted in writing.

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For members in Connecticut

Prior Auth Pass Program

All in-network doctors in Connecticut who meet certain criteria are able to participate in Anthem's Prior Auth Pass Program. Under this program, eligible doctors will no longer need to submit a request and wait for pre-approval for Anthem members* on a defined set of outpatient medical procedures done in Connecticut.

*Exceptions: BlueCard Host members, Federal Employee Program members, New York State and New York City employees

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Treating you fairly

It's important we treat you fairly

Anthem is committed to treating all members fairly and equitably. We prohibit discrimination on the basis of race, color, national origin, sex, age, or disability.

We provide:

• Equal access to health care services
• Language assistance services at no cost
• Auxiliary aids and services for people with disabilities
• Alternative formats for plan materials

If you believe you have been discriminated against, you have the right to file a grievance. Contact Member Services for assistance.

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Population Health Management Programs

Population Health Management (PHM) is a more holistic approach that prioritizes prevention and management of disease conditions.

Our PHM programs include:

• Chronic disease management for conditions like diabetes, asthma, and heart disease
• Preventive care reminders and screenings
• Health coaching and wellness programs
• Care coordination between your healthcare providers
• Educational resources and support

These programs are designed to help you stay healthy, manage chronic conditions, and improve your overall quality of life. Participation is voluntary and confidential.

To learn more or enroll in a program, call the number on your member ID card.

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Information for Colorado HMO Members

It's Anthem, Inc., our parent company, is an independent licensee of the Blue Cross Blue Shield Association.

As an HMO member in Colorado, you should know:

• You must select a Primary Care Physician (PCP) from our network
• Your PCP coordinates your care and provides referrals to specialists
• Services must be obtained from in-network providers except in emergencies
• Prior authorization may be required for certain services

For questions about your HMO plan, contact Member Services at the number on your ID card.

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For PPO members in Colorado

This notice provides a brief summary of the Life and Health Insurance Protection Association.

The Colorado Life and Health Insurance Protection Association was established to protect policyholders in the event that a member insurance company becomes insolvent.

Coverage limits and protections apply. For detailed information about the Association and your protections, visit the Colorado Division of Insurance website or contact them directly.

As a PPO member, you have:

• Flexibility to see any provider, in or out of network
• Lower out-of-pocket costs when using in-network providers
• No requirement for referrals to see specialists
• Access to a broad network of healthcare providers

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Colorado ID Card Abbreviations

Need help understanding the terms on your ID card? Here is a list of some you may see:

Common Abbreviations:

• PCP - Primary Care Physician
• Ded - Deductible
• OOP - Out-of-Pocket Maximum
• Copay - Copayment
• Coins - Coinsurance
• Rx - Prescription
• ER - Emergency Room
• UC - Urgent Care
• POS - Point of Service
• HMO - Health Maintenance Organization
• PPO - Preferred Provider Organization
• HSA - Health Savings Account
• FSA - Flexible Spending Account

If you see an abbreviation on your ID card that isn't listed here, contact Member Services for clarification.

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For members in a Colorado Option plan

Reporting data to improve health equity in Colorado

Colorado Option plans are standardized health insurance plans designed to increase affordability and access to healthcare in Colorado.

As part of the Colorado Option program, Anthem shares certain data with the state to:

• Monitor health outcomes and disparities
• Improve health equity across different populations
• Ensure compliance with state requirements
• Enhance the quality of care provided

What data is shared?

The data shared with the state includes demographic information such as:

• Age and gender
• Race and ethnicity (self-reported)
• Geographic location
• Language preference
• Utilization of healthcare services

All data is shared in compliance with HIPAA and state privacy laws. Your personal health information is protected and used only for the purposes outlined by the Colorado Option program.

For more information about the Colorado Option and data sharing practices, visit the Colorado Division of Insurance website or contact Member Services.

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Information for You at Your Fingertips! Just go to anthem.com.

• What to do when you're out of the plan's service area and need care, under "Emergency Care."
• How to access emergency care and 911 services, under "Emergency Care."
• How to find care after normal office hours, under "Hospitals-Doctors-Facilities"
• About your rights and responsibilities as a member, under "Laws and Rights that Protect You."

• About prescription drug plan, drug list/formularies and the pharmaceutical management procedures that may apply for plans with our pharmacy benefits
• How to request translation services in your preferred language and access TTY/TDD services

Go to the following locations to find:

• How to file a claim for a covered service. Go to anthem.com. Member Support/Find a Form, under Using Your Anthem Plan > Select appropriate claim form.
• How to search for doctors, specialists or hospitals in our network and learn about their qualifications. Go to anthem.com > Find Care

Need information about your policy? Just log in or register at anthem.com to:

• Search for primary and specialty care, behavioral health and hospital services.
• Learn about your copays and costs you may have to pay.
• See existing claims.
• Change your primary care physician (if it applies to your health plan).
• Order a new member ID card.
• Find information about the benefits and services covered under your plan, and any benefits that aren't covered or are limited. These include benefits that may not be covered if you go outside your plan's service area or network. You can also learn more by checking your member handbook or Certificate of Coverage
• Learn how to voice a complaint or appeal a decision, including in some cases, your right to independent external appeal
• Learn about steps we take when evaluating new treatments to be considered as covered benefits

For a printed copy of your member handbook, Certificate of Coverage or contract, call Member Services at the number on your member ID card. Mental health, pharmacy and dental services may have different phone numbers listed on the card.

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Your Case Management Program: Extra support for a serious illness or injury

Need extra help?

Our Case Management program can help when you have a serious medical condition or injury. Case managers are registered nurses or other health professionals who give telephone support when you need it most. They can help you manage your condition, assist with questions about your benefits, and help you find care or support.

This voluntary program is private and offered at no cost to you. If you change your mind about participating in the program, you can opt-out at any time. To get started, you or your caregiver can self-refer, or your doctor may refer by calling us at one of the numbers below. If you have an employer that is in different states, call Member Services at the number on your ID card.

Contact Numbers by Region:

EAST
CT	800-231-8254
ME	800-231-8254
NH	800-231-8254
NY	800-563-5909
GA	800-353-0923
VA	877-332-8193

CENTRAL
OH	1-888-662-0939/866-962-1214/800-831-7161
MO	888-662-0939/866-534-4348 (MO only)
IN	1-888-662-0939/1-866-962-1214 (IN and OH)
WI	888-662-0939/866-216-4091 (WI Only)
KY	888-662-0939/800-944-0339 (KY only) 877-636-3716 (KEHP)

WEST
CA	888-613-1130
CO	888-613-1130
NV	888-613-1130

NATIONAL
IN	800-737-1857/800-824-0581 (Transplant)
GA	866-202-8727/800-824-0581 (Transplant)
NY	855-239-0364/800-255-0881 (Transplant)
VA	877-447-5481/800-824-0581 (Transplant)
West	877-783-2756/888-574-7215 (Transplant)

FEP
All states, except CA	800-711-2225
CA	800-905-2800/800-711-2225 (HMO)

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Share for better care

Tell your primary care physician and specialists about all the care you receive

Are you telling your primary care physician (PCP) when you see a specialist or go to the emergency room? Make sure your PCP and specialists, including any behavioral health or substance use specialist know about all the care you get. This can help you avoid getting the same tests twice — and that saves time and money. It also helps to make sure you have the best care possible.

You play a big role in making sure you get the right care. Be sure to:

• Share the names of each of your providers and behavioral health practitioners with all doctors who give you care.
• Tell your doctors, especially your PCP, when you are prescribed medicine from more than one provider, are hospitalized, or see a specialist.
• Sign a consent form for the release of medical records so your information can be shared by different providers.

Remember to share for better care.

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Find in-network providers with our online provider directories

Looking for a doctor, hospital or specialist?

You can search for doctors, dentists, hospitals and specialists in English and Spanish at anthem.com.

You can search by plan type, specialty, location or gender. Learn about:

• The language the doctor speaks
• Their board certification, skills and training. Also, Member Services can help you determine the Provider's name, address, telephone number, professional qualifications, specialty, medical school attended, and board certifications. To verify Medical School, go directly to the Federation of State Medical Boards (FSMB) website at https://www.fsmb.org/. From the FSMB landing page, Click on "Find a Doctor", and then enter search criteria.

You can also use the online directories to help family members who are turning 18 and are ready to move to adult care.

If you want to learn more about a doctor in our network, call Member Services at the number on your ID card. If you don't have Internet access, Member Services can search the Web for you and then mail or send you a fax with information about network providers.

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Want to contact us but not in English? Free language help is available.

How to get help in other languages

No matter what your preferred language is, our free interpretation service can help. Just call the Member Services number on your ID card, and ask for translation services in your preferred language.

You can also ask for the translation of some written materials about your benefits. TTY/TDD services also are available by dialing 711, one of the numbers below, or by contacting Member Services. A special operator will contact us to help with your needs.

Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número telefónico de Atención a clientes que se encuentra en su tarjeta de identificación de miembro o en el folleto de inscripción.

State-by-State Contact Numbers:

State	TTY	Voice
CA	1-800-855-7100	1-800-855-8300 (STS)
CO	1-800-676-3777 (Voice/TTY)	1-800-676-3777 (Voice/TTY)
CT	1-800-842-9710 (TTY)	1-800-833-8134 (Voice)
GA	1-800-255-0056 (T)	1-800-255-0135 (V)
IN	1-800-743-3333 (V/T)	1-800-743-3333 (V/T)
KY	1-800-648-6056 (TTY/ASCII/HCO)	1-800-648-6057 (V)
ME	1-800-437-1220 (TTY)	1-800-457-1220 (Voice)
MO	1-800-735-2966 (TTY/ASCII)	1-866-735-2460 (Voice)
NV	1-800-326-6868 (TTY/ASCII/HCO)	1-800-326-6888 (Voice)
NH	1-800-735-2964 (TTY/Voice)	1-800-735-2964 (TTY/Voice)
NY	1-800-676-3777 (TTY/ASCII/Voice/VCO/STS)	1-800-676-3777 (TTY/ASCII/Voice/VCO/STS)
OH	1-800-750-0750 (TTY/Voice/HCO)	1-800-750-0750 (TTY/Voice/HCO)
VA	1-800-828-1120 (TTY)	1-800-828-1140 (Voice)
WI	1-800-947-3529 (TTY/HCO)	1-800-947-6644 (Voice)

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How to file a grievance or appeal a decision

What to do if you are unhappy with your care or service

This process applies if you're covered by Anthem Blue Cross or Anthem Blue Cross Life & Health Insurance Company (Anthem). To find out, check your member ID card.

If you are unhappy with the care or service you received from Anthem or a network medical group or health care provider, you can file a complaint. We call this a "grievance." If you disagree with a denial of treatment or claims payment, you can "appeal" the decision.

You have up to 180 calendar days from the date you get a denial notice or the date of an incident or dispute to file a grievance or appeal unless your plan documents say otherwise. If you need more time to file a grievance or appeal, you must show good cause.

How to submit a grievance or appeal:

• Member Grievance Form: Complete a Member Grievance form and mail it to: Anthem Blue Cross Life and Health Insurance Company PO Box 54149 Los Angeles, CA 90054. The form is available from your medical group, on our website or by calling Member Services at the number on your member ID card.
• Website: Go to anthem.com/ca and download the grievance or appeal form.
• Member Services: Call Member Services at the number on your ID card to file a grievance or appeal.

For emergency complaints

For any emergency grievance or appeal, call Member Services right away at the toll-free number on your member ID card.

You can choose anyone you want including an attorney or health care expert to file a grievance or appeal for you. You will be asked to fill out and sign an authorization form that allows us to speak with your representative.

What to include with your appeal

You should include with your appeal (if available):

• Your name and ID number;
• The name of the provider or facility that provided care;
• The date(s) of service;
• The claim or reference number for the specific decision with which you disagree;
• The reason you do not agree with the decision.

You have the right to include written comments, documents or other key information with your appeal. We encourage you to do so.

What happens next?

• The proper administrative and/or clinical specialists will review all information you or your representative submit with your appeal. Anthem appeals reviewers cannot be the same people who made the initial decision.
• You may contact any providers who may have more information to support your appeal.
• We will send you a written decision within 30 calendar days of getting your grievance or appeal. If your condition is urgent, we will send you a written decision within 3 calendar days of our receipt of your grievance or appeal.
• If we deny your appeal, we give you a written decision review, if available. You also can check your plan documents or call Member Services at the number on your member ID card to get more information about the appeal process.

Do you speak another language

We can help you or any member who prefers to speak in a language other than English and those with vision, speech or hearing loss by providing:

• Translation services for letters and written materials (through Member Services)
• An interpreter in a language other than English (through Member Services)
• Telephone relay systems
• Other devices to aid people with disabilities

Call Member Services

If you or a representative filed a grievance or appeal, you can call Member Services at the number on your member ID card with any questions or requests for information about your case.

*To identify the company that provides your plan, check your member ID card

Are you an ERISA plan member?

If your health benefit plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), once you have exhausted all mandatory appeal rights, you have the right to bring a civil action in federal court under section 502(a)(1)(b) of ERISA within one year, unless your plan documents provide you with more time.

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Keeping your coverage current

Important information about maintaining your benefits

To ensure your health coverage remains active and you continue to receive benefits, it's important to:

• Pay your premiums on time: Make sure your premium payments are received by the due date to avoid lapses in coverage.
• Update your information: Notify us promptly of any changes to your address, phone number, email, or family status (marriage, divorce, birth, adoption).
• Re-enroll when required: Some plans require annual re-enrollment. Watch for notices and complete the process by the deadline.
• Report changes in employment: If you change jobs or your employment status changes, contact us to understand how it affects your coverage.
• Keep your ID card: Always carry your member ID card and present it when receiving care.

If you have questions about maintaining your coverage or need to report changes, call Member Services at the number on your ID card.

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How we make coverage decisions for care and hospital stays

Understanding the authorization process

We use a process called utilization management to make sure you get the right care at the right time. This helps ensure that services are medically necessary and appropriate.

Prior Authorization

Some services require prior authorization (pre-approval) before you receive care. This includes:

• Certain surgeries and procedures
• Hospital stays (planned admissions)
• Specialty medications
• Durable medical equipment
• Some imaging services (MRI, CT scans, PET scans)

Your doctor's office typically handles the prior authorization request. We review the request and supporting medical information to determine if the service is covered under your plan.

How decisions are made

Our decisions are based on:

• Your plan's coverage guidelines
• Medical necessity criteria
• Clinical evidence and best practices
• Information provided by your healthcare provider

We'll notify you and your doctor of our decision. If a service is not approved, you have the right to appeal the decision.

For questions about prior authorization or coverage decisions, call the number on your member ID card.

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Your pharmacy coverage

Information about prescription drug benefits

Your health plan includes prescription drug coverage to help you afford the medications you need.

How to use your pharmacy benefits

• Present your ID card: Show your member ID card at any in-network pharmacy
• Check the formulary: Your plan covers medications listed on the drug formulary (list of covered drugs)
• Use generic when available: Generic medications cost less and work the same as brand-name drugs
• Mail order option: Save money on maintenance medications with 90-day supplies through mail order

Cost sharing

Your out-of-pocket costs depend on:

• The tier level of your medication (generic, preferred brand, non-preferred brand, specialty)
• Whether you use an in-network pharmacy
• Your plan's deductible and copayment/coinsurance amounts

Prior authorization and step therapy

Some medications require prior authorization or step therapy (trying a lower-cost medication first) before coverage is approved.

Find a pharmacy

Use our online pharmacy locator at anthem.com or call the pharmacy services number on your ID card to find in-network pharmacies near you.

For questions about your prescription drug coverage, call the pharmacy services number on your member ID card.

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Language assistance is available

Multi-language support for your needs

We are committed to providing language assistance services to help you understand your health benefits and access care.

Available services

• Interpretation services: Free phone interpretation in over 150 languages
• Translated materials: Key documents available in multiple languages
• Bilingual staff: Spanish-speaking representatives available
• TTY/TDD services: For members who are deaf or hard of hearing

How to access language services

Call Member Services at the number on your ID card and request an interpreter in your preferred language. An interpreter will join the call to help you communicate with our representative.

Written materials

You can request translated versions of important plan documents, including:

• Member handbook
• Summary of Benefits and Coverage
• Provider directories
• Explanation of Benefits (EOB)

All language assistance services are provided at no cost to you.

Select Your Language

Choose a language below to see this information in your preferred language:

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