Access For Infants And Mothers Program Health Maintenance

Transcription

Access for infAnts And mothers progrAm
heAlth mAintenAnce orgAnizAtion (hmo)
Anthem Blue Cross
Service Agreement and Combined
Evidence of Coverage and Disclosure Form
Effective October 1, 2012 through
September 30, 2013
Access for Infants and Mothers Program - HMO Evidence of Coverage
Timely Access to Nonemergency Health Care Services
The California Department of Managed Health Care (DMHC) adopted new regulations (Title 28,
Section 1300.67.2.2) for health plans to provide timely access to nonemergency health care services to
members. Health care service plans must comply with these regulations by January 18, 2011.
Please contact the 24/7 NurseLine at 1-800-224-0336 to access triage or screening services by
telephone, 24 hours per day, 7 days per week. If you have hearing or speech loss, you may call the
24/7 NurseLine TTY line at 1-800-368-4424.
Welcome to your health plan and thank you for choosing Anthem Blue Cross, California’s oldest and
newest health benefits company. You may know us as Blue Cross of California. Even though we have
changed our name, our purpose is the same – to be there for you. We want you to know that you have
the same choice of caring providers and health benefits as before.
This booklet tells you how your health plan works. Please take time now to look it over.
Within these pages you’ll find what you need to do if you get sick or hurt or need help. You’ll also find
ways to learn more about staying well.
If you need help or have not received your ID card, please call Customer Service at 1-877-687-0549. If you have hearing or speech loss, you may call the TTY line at 1-888-757-6034. We are only too
happy to answer your questions. To make sure the people you speak with are friendly and helpful, we
sometimes record phone calls.
Thank you again for choosing Anthem Blue Cross. We want to help you be well and stay well.
Sincerely,
Anthem Blue Cross
Access for Infants and Mothers Program - HMO Evidence of Coverage • 0910 CA0014970 9/10

Please read the following information so you will
know from whom or what group of providers you
may obtain health care.
This Combined Evidence of Coverage and
Disclosure Form constitutes only a summary of
the Health Plan’s policies and coverage under
Access for Infants and Mothers (AIM). The
Health Plan contract and the AIM regulations
(California Code of Regulations, Title 10,
Chapter 5.6) issued by the California Managed
Risk Medical Insurance Board(MRMIB), should
be consulted to determine the exact terms and
conditions of coverage. These regulations may be
viewed on the Internet at www.mrmib.ca.gov/.
Additionally, the AIM regulations require the
Health Plan to comply with all the requirements
of the Knox-Keene Health Care Service Plan
Act of 1975, as amended (California Health and
Safety Code section 1340 et seq.), and the Act’s
regulations (California Code of Regulations, Title
28). Any provision required to be a benefit of the
program by either the Act or the Act’s regulations
shall be binding on the Health Plan, even if it is
not included in the Evidence of Coverage booklet
or the Health Plan contract.
Access for Infants and Mothers Program
Combined Evidence of Coverage and Disclosure Form
Evidence of Coverage
Customer Service
This book tells you how your Anthem Blue Cross
HMO health plan for AIM works. It also tells which
health services are covered and which health services
are not covered. Please read this book completely
and carefully. For your easy reference, a benefits
summary is in Part 6. The benefits of this plan
are provided only for services that are considered
medically necessary by us. The fact that a physician
prescribes or orders a service does not, in itself, make
it medically necessary or a covered benefit.
Any questions? Call Anthem Blue Cross toll free at
1-877-687-0549 between the hours of 8:30 a.m.
to 7 p.m. If you have hearing or speech loss, you
may call our TTY line at 1-888-757-6034.
Coverage in the AIM Program for the subscriber
is as of the effective date of coverage for the
duration of the pregnancy and includes services
following the pregnancy for sixty (60) days.
Eligibility and Enrollment
Information about eligibility, enrollment, the
starting date of coverage, coverage limitations,
transfers to another health plan, infant
registration, subscriber contributions, and
disenrollment is included in the Access for Infants
and Mothers (AIM) Handbook that was mailed
to you by the AIM program. If you have questions
on these topics or would like another copy of the
Handbook, please contact the AIM program at:
ACCESS FOR INFANTS AND MOTHERS
(AIM)
PO BOX 15559
SACRAMENTO, CA 95852-0559
1-800-433-2611
The hearing impaired should call the California
Relay Service at 1-800-735-2929.
Please note: This coverage is in addition to, and
will not duplicate, any other medical benefits
available to you, whether you claim them or not.
Health Coverage for Infants through
Healthy Families Program (HFP)
Your infant is automatically eligible for enrollment
in the Healthy Families Program (HFP) if you
qualify for the Access for Infants and Mothers
(AIM) program. Once enrolled, your infant will
receive their care through the HFP by the same
health plan that you have in AIM. However, your
infant cannot be enrolled in the HFP if they are
enrolled in either employer-sponsored health
insurance or in the no-cost full-scope Medi-Cal
program. The State will mail you a packet of
information about thirty (30) days prior to your
expected due date. Once you deliver your baby,
complete and mail the Infant Registration Form,
along with other requested information, and any
premiums that are due, to the State at:
ACCESS FOR INFANTS AND MOTHERS
(AIM)
PO BOX 15559
1-800-433-2611 (phone)
1-888-889-9238 (fax)
1-800-735-2929 (California Relay service for the
hearing impaired)
Monday – Friday 8 a.m. – 8 p.m.
Saturday – 8 a.m. – 5 p.m.
Refer to the Healthy Families Program Evidence
of Coverage (EOC) booklet to learn more about
covered services for your baby.
Additional information about the AIM Program is
available at the Managed Risk Medical Insurance
Board (MRMIB) Website at www.mrmib.ca.gov/.
Help in Other Languages
If you need help in another language during your
medical visit, including when discussing complex
medical conditions and proposed treatment
options, you can request a face-to-face or telephone
interpreter. Call us at 1-877-687-0549 and we will
get someone who speaks your language to answer
your questions. If you need someone to translate
for you while you are at your doctor’s office, ask
your doctor to call us. You do not have to use a
family member or a friend to translate for you
unless you request this. We’ll be glad to help. This
help is at no cost to you.
Table of Contents
Part 1 How to Use Your Anthem Blue Cross HMO Health Plan
About Your Anthem Blue Cross HMO Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Using Your Anthem Blue Cross Identification Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Choosing a Medical Group or Primary Care Provider (PCP). . . . . . . . . . . . . . . . . . . . . .
Changing Your Medical Group or PCP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Important Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Continuity of Care for New Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Continuity of Care after Termination of Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Using Your Anthem Blue Cross HMO Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Making an Appointment with Your Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prior Authorization (an OK by Anthem Blue Cross or Your Medical Group or PCP) . . .
Getting a Standing Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Getting a Second Medical Opinion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Member Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 2 Programs to Keep You and Your Baby Well
What Should I Do First? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What if I Have Questions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24/7 NurseLine – 24-Hour Nurse Health Information Line. . . . . . . . . . . . . . . . . . . . . .
Why Shouldn’t I Smoke while Pregnant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Can Alcohol or Drugs Hurt My Baby? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What Should I Do after My Baby Is Born? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How Can I Learn More about Breastfeeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How Can I Learn More? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How Can I Keep My Newborn Healthy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 3 Emergency and Urgent Care Services
What is an Emergency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What to Do in an Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What to Do if You Are Not Sure You Have an Emergency . . . . . . . . . . . . . . . . . . . . . . .
Getting Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-Area Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Post Stabilization and Follow-up Care After an Emergency. . . . . . . . . . . . . . . . . . . . . . .
Noncovered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 4 Accessing Care
Physical Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Access for Members with Hearing or Speech Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Access for Members with Vision Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Americans with Disabilities Act of 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disability Access Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Table of Contents
Part 5 What Anthem Blue Cross Covers
Benefit Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol and Drug Abuse (Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol and Drug Abuse (Outpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ambulance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Blood and Blood Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cataract Spectacles and Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental Injury Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diabetes Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diagnostic X-ray and Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Emergency Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Education Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hearing Aids and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital Services (Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital Services (Outpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maternity Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mental Health Care Services (Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mental Health Care Services (Outpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nutrition Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orthotics and Prosthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Phenylketonuria (PKU). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physical, Occupational and Speech Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preventive Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Professional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cancer Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reconstructive Surgery: Mastectomies, Lymph Node Dissections
and Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Skilled Nursing Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Organ Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 6 Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Part 7 What Anthem Blue Cross Does Not Cover . . . . . . . . . . . . . . . . . . . . . .35
Table of Contents
Part 8 How to Get Prescription Drugs
What Can My Doctor Prescribe?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Where to Get Your Prescriptions Filled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maintenance Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 9 Grievance and Appeals Process
Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cultural and Linguistic Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Independent Medical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Independent Medical Review for Denials of
Experimental/Investigational Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Review by the Department of Managed Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . .
Binding Arbitration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part 10 If We No Longer Can Serve You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Part 11 Other Things You May Need to Know
Advance Directive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Benefits Are Not Transferable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conformity with Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Expenses in Excess of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form or Content of Evidence of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How We Pay Our Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limitations of Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Member-Provider Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Notifying You of Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Organ Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Public Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Receipt of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Third Party Recovery Process and Member Responsibilities . . . . . . . . . . . . . . . . . . . . . .
Reimbursement Provisions – If You Receive a Bill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Right to Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Terms of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nonduplication of Benefits with Worker’s Compensation . . . . . . . . . . . . . . . . . . . . . . .
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Part 12 Your Health Care Rights and Responsibilities . . . . . . . . . . . . . . . . . .53
Part 13 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Map of the Plan’s Service Area . . . . . . . . . . . . . . . . . . . . . . . . Inside back cover
Look for this symbol. It indicates that prior authorization (an OK by Anthem
Blue Cross) is needed for these services to be covered by Anthem Blue Cross.
Part 1 How to Use Your Anthem Blue Cross
HMO Health Plan
Only the member is authorized to obtain medical
services using her member identification card. If
a card is used by or for an individual other than
the member, that individual will be billed for the
services he or she receives. Additionally, if you let
someone else use your member identification card,
Anthem Blue Cross may not be able to keep you
in our plan.
About Your Anthem Blue Cross
HMO Plan
As a member of the Anthem Blue Cross HMO
plan for AIM, you are entitled to the wide range
of medical benefits specified in Part 5, What
Anthem Blue Cross Covers.
This section includes information on prenatal and
maternity care along with such preventive services
as physical exams and health education programs.
You may also refer to the table in Part 6, Benefits
Summary, which summarizes your benefits and
any limitations related to the service.
A network of well-respected health institutions,
medical groups and health professionals contract
with Anthem Blue Cross to provide you with the
medical services and supplies you are entitled to
under this Evidence of Coverage. You also may
call Anthem Blue Cross Customer Service at
1-877-687-0549 with any questions. If you have
speech or hearing loss, you may call our TTY line
at 1-888-757-6034.
Using Your Anthem Blue Cross
Identification Card
Your Anthem Blue Cross member Identification
(ID) Card not only identifies you as an Anthem
Blue Cross HMO plan AIM member, but also
lists important phone numbers. Carry your ID
card with you at all times and present it whenever
you are seeking medical care or services. You can
find your effective date of coverage on your ID
card. This is the date your health care benefits
start with Anthem Blue Cross.
Customer Service: 1-877-687-0549
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
TTY lines are only for members with hearing or speech loss.
1
anthem .com/ca
HMO Health Plan
Choosing a Medical Group or Primary Care Physician (PCP) If you live in this county:
Medical Group
If you didn’t select a medical group on your AIM
Application, Anthem Blue Cross has assigned you
one. From this medical group, which is staffed
by a team of physicians, nurses and other health
care professionals, you will be assigned your own
primary care physician (PCP). Your PCP will give
you prenatal care, as well as diagnose and treat
most illnesses. You may choose an OB/GYN from
within your assigned medical group to be your
PCP. You also may get care from an OB/GYN as
well as from your PCP.
All of your health care, including specialist
referrals when necessary, will be coordinated
through your PCP. This does not include
emergency or out-of-area urgently needed
services, which do not need an OK by your PCP
or Anthem Blue Cross. We urge you to follow
the advice your PCP offers. Your health is your
physician’s primary concern.
PCP
For members in Kern, Los Angeles and Santa
Clara counties:
Your PCP will give you prenatal care, as well as
diagnose and treat most illnesses. You may choose
an OB/GYN that works with Anthem Blue Cross
as your PCP. You may also get care from an
in-network OB/GYN as well as from your PCP. If
you didn’t select a PCP on your AIM Application,
Anthem Blue Cross has assigned you one.
Services to AIM members residing on Catalina
Island will be provided in Long Beach.
Upon enrollment, you will receive a Provider
Directory. Inside the Provider Directory, you will
find a list of doctors near you who work with
Anthem Blue Cross. The directory also includes
physicians and nonphysician providers, such
as physician assistants, nurse practitioners and
nurse midwives. You may need a referral from
your PCP to see these types of providers. If you
You can call your assigned medical group for a list did not receive a Provider Directory, you can
of physicians and nonphysician providers, such
call Anthem Blue Cross at 1-877-687-0549 or
as physician assistants, nurse practitioners, and
through our website at anthem.com/ca. If you
nurse midwives. You may need a referral from
have speech or hearing loss, you may call our
your PCP to see these types of providers. You can TTY line at 1-888-757-6034.
get the names of participating medical groups by
calling us at 1-877-687-0549. If you have speech
or hearing loss, you may call our TTY line at
1-888-757-6034.
If you are seeing a doctor who is not an Anthem Blue Cross HMO doctor for an acute or serious chronic
condition, pregnancy, a terminal illness, or surgery, you may be able to continue seeing this doctor.
This special arrangement is for a new member who has a special medical problem and is seeing a doctor
who is not an Anthem Blue Cross HMO doctor. See Part 1, How to Use Your Anthem Blue Cross
HMO Health Plan under “Continuity of Care for New Members” for more information. Or call us
at 1-877-6887-0549 to learn more. If you have speech or hearing loss, you may call our TTY line at
1-888-757-6034.
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HMO Health Plan
Changing Your Medical Group or PCP
If you live in this county:
Medical Group
If you wish to change your assigned PCP, please
call us at 1-877-687-0549. If you have speech
1-888-757-6034.
PCP
For members in Kern, Los Angeles and Santa
Clara counties:
If you need to change medical groups, please call
us at 1-877-687-0549.
Services to AIM members residing on Catalina
Island will be provided in Long Beach.
Most of the time, it’s best to keep the same PCP,
so she or he can really get to know your medical
While you’re pregnant, it’s best to keep the same needs and history. If you need or want to change
medical group, so that they can get to know your your PCP, please call us at 1-877-687-0549.
medical needs and history. However, you may
We want to do everything we can to be sure you
need to change medical groups at some time.
are happy with your doctor.
There are two reasons why you can change your
medical group.
• Youmoveoutoftheservicearea.Ifyou
move, you must notify the AIM Program of
your new address. You can request a transfer
to another medical group that is located
within 15 miles of your new residence by
calling us at 1-877-687-0549.
• Underspecialcircumstances:Anthem
Blue Cross must approve your request for
the transfer to another Anthem Blue Cross
HMO medical group to become effective.
You must notify Anthem Blue Cross in
writing of your reasons.
Anthem Blue Cross or your medical group may ask
you to change your PCP for any of the following
reasons:
• AnthemBlueCrossnolongerworkswithyour
medical group
• Youareunabletogetalongoragreewithyour
PCP
• Youkeepmakingappointmentsandnot
showing up for them
• Youareoftenverylateforyourappointments
• Youbehaveinarudeorabusiveway,ordisrupt
the medical group’s office
We will tell you in writing if we need to make this
change
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 1
How to Use Your Anthem Blue Cross
HMO Health Plan
treatment to maintain remission or prevent
deterioration. Completion of covered services
shall be provided for a period of time necessary
to complete a course of treatment and to arrange
for a safe transfer to another provider, as
determined by Anthem Blue Cross in
consultation with the member and the
nonparticipating provider and consistent with
good professional practice. Completion of
covered services shall not exceed twelve (12)
months from the time the member enrolls with
Anthem Blue Cross.
Important Note
Some hospitals and other providers do not provide
one or more of the following services that you
might need:
•Familyplanning
•Contraceptiveservices,includingemergency
contraception
•VoluntaryTerminationofPregnancy
•Sterilization,includingtuballigationatthe
time of labor and delivery
You should obtain more information from your
desired medical group before you select them.
Call your prospective medical group, or call us at
1-877-687-0549 to ensure that you can obtain
the health care services that you need. If you have
at 1-888-757-6034.
3. You are pregnant. A pregnancy is the three
trimesters of pregnancy and the immediate
postpartum period. Completion of covered
services shall be provided for the duration of
the pregnancy.
4. You have a terminal illness. A terminal illness
is an incurable or irreversible condition that
has a high probability of causing death within
one (1) year or less. Completion of covered
the terminal illness.
Continuity of Care for New Members
Under some circumstances, Anthem Blue Cross
will provide continuity of care for new members
who are receiving medical services from a
nonparticipating provider. If you are a new
member, you may request continuity of care if any
one of the following conditions applies:
5. You have surgery or other procedure that we
have authorized as part of a documented course
of treatment and that has been recommended
and documented by the provider to occur
within 180 days of the time the member
enrolls with Anthem Blue Cross.
1. You have an acute condition. An acute
condition is a medical condition that involves
a sudden onset of symptoms due to an illness,
injury or other medical problem that requires
prompt medical attention and that has a
limited duration. Completion of covered
the acute condition.
Please contact us at 1-877-687-0549 to request
continuing care or to obtain a copy of our
Continuity of Care policy. If you have speech or
hearing loss, you may call our TTY line at
1-888-757-6034. Eligibility to receive continuity
of care is normally based on your medical
condition. Eligibility is not based strictly upon the
name of your condition. Continuity of care does
not provide coverage for services not otherwise
covered under the agreement.
2. You have a serious chronic condition. A serious
chronic condition is a medical condition due to
a disease, illness or other medical problem or
medical disorder that is serious in nature and
that persists without full cure or worsens over an
extended period of time or requires ongoing
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Part 1
HMO Health Plan
We will notify you by telephone, and the provider
by telephone and fax, whether your request for
continuity of care has been approved. Financial
arrangements with nonparticipating providers are
negotiated on a case-by-case basis. We will request
that the nonparticipating provider agree to the
same contractual terms and conditions that are
imposed upon participating providers providing
similar services, including payment terms. If the
nonparticipating provider does not accept the
terms and conditions, Anthem Blue Cross is not
required to continue that provider’s services.
Anthem Blue Cross is not required to provide
continuity of care as described in this section to a
newly covered member who was covered under an
individual member agreement and undergoing a
treatment on the effective date of her AIM
coverage. Continuity of care does not provide
coverage for benefits not otherwise covered under
this agreement.
writing to accept the terms and reimbursement
rates under his/her agreement with Anthem
Blue Cross prior to termination. If the provider
does not agree with these contractual terms and
conditions, we are not required to continue
the provider’s services beyond the contract
termination date.
2. Anthem Blue Cross will furnish such benefits
for the continuation of services by a terminated
provider only for any of the following reasons:
• Youhaveanacutecondition.Anacute
condition is a medical condition that involves
a sudden onset of symptoms due to an illness,
injury or other medical problem that requires
prompt medical attention and that has a
limited duration. Completion of covered
the acute condition.
• Youhaveaseriouschroniccondition.A
serious chronic condition is a medical
condition due to a disease, illness or other
medical problem or medical disorder that is
serious in nature and that persists without
full cure or worsens over an extended period
of time or requires ongoing treatment to
maintain remission or prevent deterioration.
Completion of covered services shall be
provided for a period of time necessary
to complete a course of treatment and to
arrange for a safe transfer to another provider,
as determined by Anthem Blue Cross in
consultation with the member and the
terminated provider and consistent with good
professional practice. Completion of covered
services shall not exceed twelve (12) months
from the provider’s contract termination date.
If you disagree with our determination regarding
continuity of care for new members, see Part 9,
Grievance and Appeals Process.
Continuity of Care after Termination of
Provider
If your primary care provider or other health care
provider stops working with Anthem Blue Cross,
we will let you know by mail sixty (60) days before
the contract termination date. Subject to the terms
and conditions set forth below, Anthem Blue Cross
will pay benefits at the participating provider level
for covered services rendered to a member by a
provider whose participation we have terminated.
1. The member must be under the care of the
participating provider at the time of our
termination of the provider’s participation. The
terminated provider must agree in writing to
provide services to the member in accordance
with the terms and conditions of his/her
agreement with Anthem Blue Cross prior to
termination. The provider must also agree in
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 1
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• Youarepregnant.Apregnancyisthethree
trimesters of pregnancy and the immediate
postpartum period. Completion of covered
the pregnancy.
and/or contractual requirements, we are not
required to continue that provider’s services.
If you disagree with our determination regarding
continuity of care, see Part 9, Grievance and
Appeals Process.
• Youhaveaterminalillness.Aterminalillness
is an incurable or irreversible condition
that has a high probability of causing death
within one (1) year or less. Completion of
covered services shall be provided for the
duration of the terminal illness.
Using Your Anthem Blue Cross HMO
Benefits
Your medical group or PCP is responsible for
all your care. Your medical group or PCP is
responsible for authorizing all the care you receive.
This does not include emergency or out-of-area
urgently needed services, which do not need an
OK by your medical group, PCP or Anthem
Blue Cross. An AIM HMO member can see
an in-network OB/GYN for specialty services
without a prior authorization. If you have any
questions, call your medical group or PCP.
• Youhavesurgeryorotherprocedurethat
we have authorized as part of a documented
course of treatment and that has been
recommended and documented by the
provider to occur 180 days of the provider’s
contract termination date.
3. Such benefits will not apply to providers
who have been terminated due to medical
disciplinary cause or reason, fraud or other
criminal activity.
Making an Appointment with Your
Doctor
When scheduling an appointment with your
medical group or PCP, tell them you are an
Anthem Blue Cross HMO member for AIM.
Have your Anthem Blue Cross HMO for AIM
card with you when you call; you may be asked
for the numbers on the card.
Please contact us at 1-877-687-0549 to request
continuing care or to obtain a copy of our
Continuity of Care policy. If you have speech or
1-888-757-6034. Eligibility to receive continuity
of care is normally based on you medical
condition. Eligibility is not based strictly upon the
name of your condition. Continuity of care does
not provide coverage for benefits not otherwise
covered under the agreement.
We will notify you by telephone and the provider
by telephone and fax, as to whether or not your
request for continuation of care is approved.
Financial arrangements with terminated providers
are negotiated on a case-by-case basis. We will
request that the terminated provider agree to
negotiate reimbursement and/or contractual
requirements that apply to participating providers,
including payment terms. If the terminated
provider does not agree to the same reimbursement
When you are pregnant, it’s important to see your
doctor right away and get your care started.
Your medical group or PCP may be reached on
a 24-hour basis at the number on your card.
Either your own PCP will call you back after you
leave your name and telephone number with the
answering service, or a doctor on call will get back
to you with the medical advice that you need.
When you have an appointment, be on time. Call
your medical group or PCP’s office as soon as
possible if:
• Youaregoingtobelate.
• Youareunabletogotoyourappointment.
6
Part 1
HMO Health Plan
Anthem Blue Cross providers have ramps,
restrooms, parking spaces and elevators for
disabled members so they can get the health care
they need.
care has been authorized. Payment for services
rendered without prior authorization from your
medical group or PCP or Anthem Blue Cross will
be your responsibility. If you see a specialist or
receive specialty services from a provider inside or
outside of the network before you receive the OK
from Anthem Blue Cross, you will be responsible
to pay for the cost of the treatment.
Prior Authorization (an OK by
Anthem Blue Cross or your Medical
Group or PCP)
Requires prior authorization
Services which require prior authorization include,
but are not limited to:
If you need special care, your medical group or
PCP may send you to a different health care
provider. The staff at your medical group or PCP’s
office will help you make the appointment for
the special health care you need. Tell your PCP or
other health care provider as much as you can, so
you and your doctor can decide together what is
best for you.
If you are referred, your medical group or PCP will
give you an “Authorization for Referral Services”
form that specifies exactly what treatment or
services your medical group or PCP authorizes.
Take this form to the health care provider you have
been referred to on the appointment date shown
on the authorization form. That provider will
complete the authorization form and send it back
to your medical group. If you do not receive the
authorization form, please inform your medical
group or PCP.
The reason the referral provider sends the form
back is so that your medical group or PCP can
coordinate the payment for the special services.
You should not be billed for referral services.
However, if you receive a bill, send it to your
medical group’s coordinator who will see that
payment is made.
• Allinpatienthospitalcare
• Ambulatoryandothersurgicalcare
• Allinfusiontherapies
• Physical,speechandoccupationaltherapies
• CT,MRI,MRA,PETandSPECT
• Transplantsandimplants(allorgansand
tissues)
• Cataractspectaclesandlenses
• Custommadedurablemedicalequipment
• Homehealthcare
• Septoplasty
• Hospice
• Selectprescriptiondrugs
Once Anthem Blue Cross receives a request for
prior authorization from your doctor, we will
approve, modify or deny the service within:
• Fivebusinessdaysfromthetimewereceive
the request for all routine services based upon
the nature of the member’s medical condition.
• 72hoursfromthetimewereceivetherequest
for all urgently needed services based upon the
nature of the member’s medical condition.
Remember that payment will be made only for
the number of visits and the medical care that is
specifically authorized by your medical group or
PCP. Before getting any other care, check with
your medical group or PCP to make sure that such
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 1
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are not required to, speak to your primary care
provider if you want a second opinion. You may
request a second opinion for any reason, including
the following:
Emergency or out-of-area urgently needed services
do not need an approval by your medical group,
PCP or Anthem Blue Cross. You may see an innetwork OB/GYN for specialty service without a
prior authorization.
• Youhavequestionsaboutarecommended
surgery.
Anthem Blue Cross works with you and your
doctors to cover medically necessary and proper
care and services. A medical necessity review may
be called a utilization review (UR), utilization
management (UM) or medical management.
For information on how our utilization review
process works, please call Anthem Blue Cross at
1-877-273-4193.
• Youhavequestionsaboutatreatmentplanfor
a chronic condition; or a condition that could
cause loss of life, limb or body function.
• Yourdoctor’sadviceeitherisnotclearoristoo
complex.
• Thediagnosisprovidedisnotconsistentwith
the test results.
Remember:
• Yourdoctorcannotdiagnoseyourmedical
condition.
We only pay for the number of visits and the type
of special care that your primary care provider
OKs. Call your doctor if you need more care. If
your care isn’t approved ahead of time, you will
have to pay for it (except for emergencies).
Getting a Standing Referral
If you have a life-threatening, degenerative or
disabling condition and need special care for
a long period of time, you may need ongoing
care from a specialist. Your PCP may suggest a
standing referral to the specialist instead of giving
you a referral for each visit. You can also ask for a
standing referral.
If you receive a standing referral to a specialist
within our network, the referral does not
need prior approval from Anthem Blue Cross.
However, your PCP must get prior approval
from Anthem Blue Cross if the specialist does not
participate in our network.
Getting a Second Medical Opinion
Sometimes you may have questions about
your illness or your primary care provider’s
recommended treatment plan. You should, but
• Atreatmentplanisnotimprovingyour
condition.
• Youareconcernedaboutyourdoctor’s
treatment plan.
If your request to obtain a second opinion about
care provided by your primary care provider is
authorized, you will receive a second opinion from
an appropriately qualified health care professional
of your choice within your network. If you request
to obtain a second opinion about care provided by
a specialist is authorized, you will receive a second
opinion from an appropriately qualified specialist
of your choice within your network. If there is no
appropriately qualified health care professional
within Anthem Blue Cross’ network, Anthem
Blue Cross will authorize a second opinion from
an appropriately qualified nonparticipating
health care professional. Anthem Blue Cross will
consider your ability to travel.
When you ask for a second opinion, Anthem
Blue Cross will decide quickly. If the medical
condition is a chronic illness, or could cause loss of
life, limb, or body function, Anthem Blue Cross
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Part 1
HMO Health Plan
• Servicesfromanon-participatingprovider,
unless the services are for situations allowed
in this Evidence of Coverage booklet (for
example, emergency services, urgent services
outside of the Anthem Blue Cross service area,
or specialty services approved by Anthem
Blue Cross (see page 18 Prior Authorization
(an OK by Anthem Blue Cross or your
Medical Group or PCP); or
will decide within 72 hours. For more information
about second opinions, call us at 1-877-687-0549
or call 24/7 NurseLine, the 24-hour nurse health
information line, at 1-800-224-0336.
If you are denied a second opinion, you may
appeal by following Anthem Blue Cross’ grievance
procedures. See Part 9, Grievance and Appeals
Process to file a complaint or grievance.
Coordination of Benefits
• Servicesyoureceivedthataregreaterthanthe
limits described in this Evidence of Coverage
booklet unless authorized by Anthem
Blue Cross.
If you are covered by another health plan, please
call us at 1-877-687-0549. If you have speech
1-888-757-6034. If you are covered by another
health plan, that plan will pay first and Anthem
Blue Cross will pay second. The total of the two
payments cannot be more than the total amount
allowed by Anthem Blue Cross.
Anthem Blue Cross is responsible to pay for all
covered services including emergency services. You
are not responsible to pay a provider for any amount
owed by the health plan for any covered service.
If Anthem Blue Cross does not pay a
nonparticipating provider for covered services, you
Member Liabilities
do not have to pay the nonparticipating provider
In AIM, there are no member copays for covered
for the cost of the covered services. Covered
services. As long as you are receiving covered
services are those services that are provided
services you should not have to pay anything.
according to this Evidence of Coverage booklet.
You may have to pay for services you receive that
The nonparticipating provider must bill Anthem
are NOT covered services, such as:
Blue Cross, not you, for any covered services.
• Nonemergencyservicesreceivedinthe
But remember, services from a nonparticipating
emergency room;
provider are not “covered services” unless they fall
• Nonemergencyornonurgentservicesreceived within the situations allowed by this Evidence of
outside of the Anthem Blue Cross service area Coverage booklet.
if you did not get authorization from Anthem If you receive a bill for a covered service
Blue Cross before receiving such services
from any provider, whether participating or
nonparticipating, contact the Anthem Blue Cross
• Specialtyservicesyoureceiveifyoudidnot
Customer Service at 1-877-687-0549. If you
get a required referral or authorization from
have speech or hearing loss, you may call our TTY
Anthem Blue Cross before receiving such
line at 1-888-757-6034.
services (see page 18, Prior Authorization
(an OK by Anthem Blue Cross or your
Medical Group or PCP);
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 2
Programs to Keep You and
Your Baby Well
What Should I Do First?
First, if the assigned medical group is not the right
one for you, please call us at 1-877-687-0549
to change to a new medical group. If you have
at 1-888-757-6034.
Second, call and make an appointment with your
new PCP as soon as you receive your Anthem
Blue Cross ID card. Remember, when you are
pregnant, it is important to begin your health care
right away!
Third, call us and tell us at which hospital your
baby will be delivered.
What If I Have Questions?
If you need to consult a doctor, your PCP is
available by phone 24-hours a day.
24/7 NurseLine – 24-Hour Nurse
Health Information Line
Anthem Blue Cross gives you a 24-hour nurse
health information line. This service is staffed by
registered nurses who can help you in many ways:
• Helpyoumakegoodhealthcaredecisions
• Giveadviceaboutwhentovisityourdoctor
Call 1-800-224-0336 to use this program. If you
have speech or hearing loss, you may call the 24/7
NurseLine TTY line at 1-800-368-4424.
Why Shouldn’t I Smoke while Pregnant?
When you’re pregnant, it is important to give your
baby a healthy start. Learn why this is a good time
to stop smoking and how to do it. It is important
to your and your baby’s health to stay smoke free:
• Duringpregnancy.
Tobacco smoke contains thousands of chemicals.
You can protect yourself and your family from
secondhand smoke. It comes from two places:
• Smokebreathedoutbythepersonwhosmokes
• Smokefromtheendofaburningcigarette
Many times you can’t see or smell smoke in the
air, but the chemicals from tobacco are still there.
The California Smokers’ Helpline is a telephone
program that can help you quit smoking. Helpline
services are free and are funded by the California
Department of Health. When you call, a friendly
staff person will offer a choice of services such as
self-help materials, a referral list of other programs
and one-on-one counseling over the phone.
Whether you’re ready to quit or just thinking
about it, call 1-800-NO-BUTTS.
Can Alcohol or Drugs Hurt My Baby?
When you drink or use other drugs, even
prescription drugs, so does your baby. Alcohol
and other drugs can hurt your unborn or nursing
baby. Your unborn baby’s health depends on you.
Don’t use alcohol and other drugs, and take care
of yourself. Ask your doctor for help.
What Should I Do after My Baby Is
Born?
Your baby will be automatically eligible for
enrollment in the Healthy Families Program
(HFP). One month before your due date, you will
receive a packet of information telling you how to
obtain HFP coverage for your baby. You can call
the AIM program toll-free at 1-800-433-2611.
If you have speech or hearing loss, you may call
the TTY line at 1-800-735-2929 if you have
questions.
• Afteryourbabyisborn.
• Fortherestofyourlife.
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Part 2
Programs to Keep You and
Your Baby Well
Your medical care doesn’t end after your baby
is born. New moms need to see a doctor. Your
postpartum checkup is an important part of your
care. Your doctor will make sure you are healing
properly. This is also a good time to ask questions
about:
How Can I Learn More?
Our prenatal program is designed to reduce risks
to infants by educating expectant mothers on
the care needed while pregnant. The program
includes a post partum exam reminder and reward
for completing your post partum exam. Call
us at 1-877-687-0549 to learn more about the
program. If you have hearing or speech loss, you
• Breastfeeding
• Birthcontrol
• Dietandexercise
How Can I Keep My Newborn Healthy?
Before you leave the hospital, your doctor will tell
you when you need to come in for your checkup.
If you have questions about your postpartum visit,
be sure to ask your doctor. Remember – your
baby needs a happy and healthy mom!
Babies go to the doctor a lot even when they’re
healthy! Make sure you fill out the forms to
enroll your baby in the HFP. Once your baby is
enrolled in the HFP, pick a pediatrician, general
practitioner, or a family practice physician for
your baby. Make an appointment as soon as your
baby is born.
How Can I Learn More about
Breastfeeding?
We know that breastfeeding is important to you.
It is also important to the health of your baby.
Breastfed babies are protected against certain
diseases during the first months. If you are
breastfeeding or thinking about it, you may need
to learn more about how to breastfeed. Many
women quit simply because they cannot get
answers to their questions or solve problems they
are having.
Before leaving your baby’s doctor’s office, schedule
your baby’s next well-baby appointment. This way,
you’ll make sure your baby gets all the care needed.
Because breastfeeding is so important to your
newborn, Anthem Blue Cross offers a free
Breastfeeding Support Line. Call the toll-free
number at 1-800-231-2999. If you have speech
or hearing loss, you may call the 24/7 NurseLine
TTY line at 1-800-368-4424. Listen to the
recording. Follow the directions. You will be
connected to one of the nurses. Try it. It’s easy.
You can call the Breastfeeding Support Line as
often as you need it.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 3
Emergency and Urgent Care
What Is an Emergency?
What to Do in an Emergency
An emergency is a medical or psychiatric
condition with such severe symptoms (including
active labor or severe pain) that a prudent lay
person, who has an average knowledge of health
and medicine, could reasonably believe that the
lack of immediate medical attention could:
In an emergency, get help immediately. Call
911 or go to the nearest emergency room for
emergency care.
• Placeyourhealth(orthehealthofyour
unborn baby) in jeopardy.
• Causeimpairmenttoabodyfunction.
• Causedysfunctionofabodyorganorpart.
Examples include:
You or your doctor must call Anthem Blue Cross
within 48 hours, or as soon as reasonably possible,
if you are admitted to a hospital in an emergency
situation. If you or your doctor do not call
Anthem Blue Cross within that time after you are
admitted to a hospital in an emergency situation,
you may be liable for some charges.
Call 911 or go to the nearest emergency room
for emergency care.
• Brokenbones
• Chestpain
• Severeburns
• Fainting
• Drugoverdose
• Paralysis
• Severecutsthatwon’tstopbleeding
• Psychiatricmedicalemergencyconditions
Emergency services are covered inside and outside
of Anthem Blue Cross’ service area. Outside
of your service area, treatment for emergencies
includes urgently needed services to prevent
serious deterioration of your health resulting from
unforeseen illness or injury for which treatment
cannot be delayed until you return to your service
area.
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Part 3
To obtain urgent care when you are inside
Anthem Blue Cross’ service area on nights and
weekends, you can reach your PCP 24 hours a
day at the number on your member ID card.
Either your own PCP will call you back, after
you leave your name and telephone number
with the answering service, or an on-call doctor
will get back to you with the medical advice that
you need. You may also call 24/7 NurseLine, the
24-hour nurse health information line. The 24/7
NurseLine number is 1-800-224-0336. If you
have speech or hearing loss, you may call the 24/7
NurseLine TTY line at 1-800-368-4424.
What to Do if You Are Not Sure You
Have an Emergency
If you are not sure whether you have an
emergency or require urgent care, your medical
group or PCP may be reached 24 hours a day.
Either your own doctor will call you back, after
you leave your name and telephone number with
the answering service, or a doctor on call will get
back to you with the medical advice you need. If
you are not sure whether you have an emergency
or require urgent care, please contact the 24/7
NurseLine, the 24-hour nurse health information
line to access triage or screening services 24 hours
a day, 7 days a week. The 24/7 NurseLine number
is 1-800-224-0336. If you have speech or hearing
loss, you may call the 24/7 NurseLine TTY line at
1-800-368-4424.
To obtain urgent care when you are outside
Anthem Blue Cross’ service area, you can call 24/7
NurseLine, our 24-hour nurse health information
line. The nurse can answer your questions and
help you locate an urgent care provider. You
should seek urgent care services at the closest
urgent care provider when you are outside the
Anthem Blue Cross service area.
Getting Urgent Care
On your first visit, talk to your PCP about what he
or she wants you to do when the office is closed.
Urgent care services are services needed to prevent
an unforeseen illness, an injury, prolonged pain or
a complication of an existing condition, including
pregnancy, for which treatment cannot be delayed.
Anthem Blue Cross covers urgent care services any
time you are outside our service area or on nights
and weekends when you are inside our service
area. To be covered, the urgent care service must
be needed because the illness or injury will become
much more serious if you wait for a regular doctor’s
appointment.
You do not need an approval from Anthem
Blue Cross to obtain urgent care services when
you are outside Anthem Blue Cross’ service area.
Out-of-Area Care
Out-of-area care is limited to emergency services,
including urgently needed services to prevent
area. These services are only covered until your
medical group or PCP can arrange for care within
the Anthem Blue Cross HMO network.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 3
Poststabilization and Follow-up Care
After an Emergency
Once your emergency medical condition has been
treated at a hospital and an emergency no longer
exists because your condition is stabilized, the
doctor who is treating you may want you to stay
in the hospital for a while longer before you can
safely leave the hospital. The services you receive
after an emergency condition is stabilized are
called “post-stabilization services.”
If the hospital where you received emergency
services is not part of Anthem Blue Cross’
contracted network (“noncontracted hospital”),
the noncontracted hospital will contact Anthem
Blue Cross to get approval for your stay in the
noncontracted hospital.
If Anthem Blue Cross approves your continued
stay in the noncontracted hospital, you will not
have to pay for services except for any copayments
normally required by Anthem Blue Cross.
Also, you may have to pay for services if the
noncontracted hospital cannot find out what your
name is and cannot get contact information at the
plan to ask for approval to provide services once
you are stable.
If you feel that you were improperly billed
for poststabilization services that you received
from a noncontracted hospital, please contact
Anthem Blue Cross’ Customer Services at
1-877-687-0549 between the hours of 8:30 a.m.
to 7p.m. If you have hearing or speech loss, you
Noncovered Services
Medical services that are done in an emergency
care or urgent care setting for conditions that are
not emergencies or urgent are not covered under
this plan. You will be responsible for all charges
related to these services.
If Anthem Blue Cross has notified the
noncontracting hospital that you can safely be
moved to one of the plan’s contracted hospitals,
Anthem Blue Cross will arrange and pay for you
to be moved from the noncontracted hospital to a
contracted hospital.
If Anthem Blue Cross determines that you can be
safely transferred to a contracted hospital, and you
or your spouse or legal guardian do not agree to
you being transferred, the noncontracted hospital
must give you or your spouse or legal guardian a
written notice stating that you will have to pay
for all of the cost for poststabilization services
provided to you by the noncontracted hospital
after your emergency condition is stabilized.
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Part 4
Accessing Care Physical Access
The Americans with Disabilities Act of
1990
Anthem Blue Cross has made every effort to ensure
that our offices and the offices and facilities of
Anthem Blue Cross providers are accessible to the
disabled. If you are not able to locate an accessible
provider, please call us toll-free at 1-877-687-0549
and we will help you find an alternate provider. If
you have hearing or speech loss, you may call our
TTY line at 1-888-757-6034.
Anthem Blue Cross complies with the Americans
with Disabilities Act (ADA) of 1990. This federal
law protects you from being treated differently by
us because you are disabled. Section 504 of the
Rehabilitation Act of 1973 states that no qualified
disabled person shall, because of a disability, be
kept from taking part in, be denied the benefits
of, or not be treated the same as others under
any program or activity that gets or benefits from
federal funds.
Access for Members with Hearing or
Speech Loss
If you have hearing or speech loss, you may
contact us through our TTY number at
1-888-757-6034, Monday through Friday, from
8:30 a.m. to 7 p.m. Between 7 p.m. and 8:30 a.m.
and on weekends, please call the California Relay
Service TTY at 711 to get the help you need. You
can also call the 24/7 NurseLine. That phone
number is 1-800-224-0336. If you have hearing
or speech loss, the 24/7 NurseLine TTY line is
1-800-368-4424.
Programs or activities that get money from
the state of California must follow California
Government Code Section 11135, which does
not allow you to be treated different for any of
these reasons:
• Ethnicgroup
• Religion
• Age
• Sex
Access for Members with Vision Loss
• Color
This Evidence of Coverage (EOC) and other
important plan materials will be made available in
alternative formats for members with vision loss.
For example, large print and enlarged computer
disk formats, Braille or audiotape. To get these
other formats, or for help in reading the EOC
and other plan materials, please call us at
1-877-687-0549. Members with vision loss can
get this EOC and other plan materials in other
formats such as:
• Disability
• Largeprint
• Computerdiskformat
• Braille
TTY: 1-888-757-6034
• Audiotape
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
Sign language services are available.
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Part 4
Accessing Care Disability Access Grievances
If you believe Anthem Blue Cross or a provider in
your network has not met your disability access
needs, you may file a complaint with us by calling
our toll-free Customer Service or TTY phone
number. If you believe you have not been treated
the same as others because of your disability,
please call us.
If your disability access complaint remains
unresolved, you may contact the:
ADA COORDINATOR
MANAGED RISK MEDICAL
INSURANCE BOARD
PO BOX 2769
1-916-324-4695
The hearing impaired should call the California
Relay Service at 711.
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Part 5
What Anthem Blue Cross Covers
The benefits described in this Evidence of
Coverage apply to the covered service for
treatment of a covered illness, injury or condition
that occurs while you are a member of this plan.
Alcohol and Drug Abuse (Inpatient)
Hospitalization for alcoholism or drug abuse as
medically necessary to remove toxic substances
from the system.
Infants born to AIM mothers are automatically
eligible for enrollment in the Healthy Families
Program (HFP). For more information, please
refer to Health Care Coverage for Infants on the
page before the Table of Contents in this EOC.
Alcohol and Drug Abuse (Outpatient)
Treatment of alcoholism or drug abuse. This
coverage is limited to 20 visits per benefit year
that can consist of individual, family and/or
group sessions, physician/psychiatrist visits for
mental health medication management, and/or
physician/psychiatrist outpatient consultations.
This includes crisis intervention and treatment of
alcoholism or drug abuse on an outpatient basis as
medically necessary.
Please remember that all services, except
emergency or out-of-area urgently needed
services, family planning services, and in-network
OB/GYN care, must be preapproved by your PCP
or medical group and/or Anthem Blue Cross. If
you have any questions about what is covered, call
us at 1-877-687-0549. If you have hearing or
speech loss, you may call our TTY line at
1-888-757-6034.
Services received from a nonparticipating or
out-of-state provider without an authorized referral
will not be covered except for emergency or out-of
area urgently needed services. Services provided
by nonparticipating and out-of-state providers are
covered for medical emergencies, urgently needed
services or authorized referrals only.
Ambulance Services
If you have any questions about what is covered,
call us at 1-877-687-0549. If you have hearing
or speech loss, you may call our TTY line at
1-888-757-6034.
Nonemergency transportation for the transfer
from a hospital to another hospital or facility, or
from a facility to home is covered when:
Emergency ambulance services must be from a
licensed ambulance company or air ambulance
in connection with emergency services to the
first hospital that accepts you for emergency care.
Includes services provided through the “911”
emergency system.
• Medicallynecessary.
Benefit Limitations
• RequestedbyanAnthemBlueCrossdoctor.
Some of the services listed below have limited
benefits such as maximum day or visit limitations
(for example, home health visits and psychiatric
services for mental or nervous disorders). You
will be responsible for any amount exceeding the
maximum day or visit limitation.
• OK’dinadvancebyAnthemBlueCross.
Excluded is coverage for transportation by
airline, passenger car, taxi or other form of public
conveyance.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
Blood and Blood Products
Diabetes Treatment
Processing, storage and administration of blood
and blood products in the inpatient and outpatient
settings. Includes the collection and storage of
autologous blood when medically indicated.
Diabetes self-management training provided
to qualified members after the initial diagnosis
of diabetes in the care and management of that
condition, nutritional counseling and proper use
of diabetes equipment and supplies are covered.
A health care practitioner or provider licensed,
registered, or certified in California to provide
appropriate health care services must provide
diabetes self-management training.
Cataract Spectacles and Lenses
Cataract spectacles, cataract contact lenses, or
intraocular lenses that replace the natural lens
of the eye after cataract surgery. Also one pair of
conventional eyeglasses or conventional contact
lenses is covered if medically necessary after cataract
surgery with insertion of an intraocular lens. The
surgery to remove the cataract and insert a lens in
the eye needs an OK from Anthem Blue Cross.
•Additionaltrainingauthorizedonthe
diagnosis of a doctor or other health care
practitioner of a significant change in the
qualified member’s symptoms or condition
that requires changes in the qualified
member’s self-management regime
• Maybeusedinlieuofshort-term
rehabilitation therapy
•Periodicorepisodiccontinuingeducation
when prescribed by an appropriate health care
practitioner as warranted by the development
of new techniques and treatments for diabetes
• Subjecttolimitationsofshort-termtherapy
•Therapeuticfootwearfordiabetes
Chiropractic Services
Dental Injury Treatment
•Thefollowingdiabetesequipmentandsupplies:
A physician (MD) or dentist (DDS or DMD)
may treat you for an accidental injury to natural
teeth or jaw, if the injury occurs while you are
covered under this plan. Services must begin
within 90 days after the date you are injured or as
soon as medically possible.
– Blood glucose monitors, including monitors
designed to assist the visually impaired, and
blood glucose testing strips
– Insulin pumps and all related necessary
supplies
– Ketone urine testing strips
•Generalanesthesiaandassociatedfacility
charges in connection with dental procedures
when the use of a hospital or surgery center is
medically necessary because of an underlying
medical condition or clinical status or because
of the severity of the dental procedure.
– Lancets and lancet puncture devices
– Pen delivery systems for the administration
of insulin
– Podiatric devices to prevent or treat
diabetes-related complications
Damage to natural teeth caused by chewing or
biting is not accidental injury and is excluded.
– Insulin syringes and needles
– Visual aids, excluding eyeglasses, to assist
members with vision loss with proper
dosing of insulin
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Part 5
• Thefollowingdiabetesmedications:
Durable Medical Equipment and
Supplies
− All forms of rapid, intermediate and longacting insulins
− Oral and self-injectable diabetes medications
•Medicalequipmentappropriateforusein
the home that is intended for repeat use,
is generally not useful to a person who is
not ill or injured, and primarily serves a
medical purpose. Call us at 1-877-687-0549
to determine whether to rent or purchase
standard equipment. If you have speech or
1-888-757-6034.
− Glucagon
Diagnostic X-ray and Laboratory
Services
•Diagnosticlaboratoryservices,diagnostic
imaging, diagnostic and therapeutic
radiological services necessary to appropriately
evaluate, diagnose, treat and follow up on
care of members. Other diagnostic services,
which shall include, but are not limited to
electrocardiography; electroencephalography;
prenatal diagnosis of genetic disorders of the
fetus in cases of high-risk pregnancy, and
mammography for screening or diagnostic
purposes. Laboratory tests appropriate for
the management of diabetes, including
at a minimum, cholesterol, triglycerides,
microalbuminuria, HDL/LDL and
hemoglobin A-1C (glycohemoglobin)
Custom-made durable medical equipment needs
an OK from Anthem Blue Cross.
•Oxygenandoxygenequipment
•Apneamonitors
•Adultnebulizermachines,tubing,facemasks
and related supplies, and peak flow meters
used for management of asthma
•Ostomysupplies
•Urinarycathetersandsupplies
•Otherlong-lastingmedicalequipmentand
supplies
•YoumaygetanyFDA-approvedtestthat
screens for cancer of the cervix, including the
human papillomavirus (HPV) test, along with
the Pap smear. Your health care provider must
refer you for this test.
•Repairorreplacementcosts,unless
necessitated by misuse or loss
Emergency Health Care Services
All high-cost radiology such as CT, MRI,
MRA, PET and SPECT need an OK from
Anthem Blue Cross.
24-hour emergency care provided by any hospital,
even if it is not part of the Anthem Blue Cross
network or within your service area.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
•Drugandalcoholabuse(theeffectsofdrugsor
alcohol on your health, signs of alcohol or drug
abuse, where to get help if you or someone you
know has a drug or alcohol problem)
Family Planning Services
Voluntary family planning services are covered,
including:
•Counselingandsurgicalproceduresfor
sterilization as permitted by state and federal
law.
Hearing Aids and Services
•CoveragefordiaphragmsandotherfederalFood Audiological evaluation to measure the extent
and Drug Administration-approved devices
of hearing loss and a hearing aid evaluation to
pursuant to the prescription drug benefit
determine the most appropriate make and model
of hearing aid are covered.
• Voluntaryterminationofpregnancy
•Monauralorbinauralhearingaidsincluding
ear mold(s)
Exclusion
Treatment for infertility is excluded.
Note: Some hospitals and other providers do not
provide one or more of the following services:
family planning; contraceptive services, including
emergency contraception; sterilization, including
tubal ligation at the time of labor and delivery;
infertility treatments or abortion. Call your
prospective doctor, medical group, independent
practice association or Anthem Blue Cross at
1-877-687-0549 to ensure that you can obtain
the health care services that you need. Members
with hearing or speech loss may call the Anthem
Blue Cross TTY line at 1-888-757-6034.
•Hearingaidinstrument
•Theinitialbattery
•Cordsandotherancillaryequipment
•Visitsforfitting,counseling,adjustments,
repairs, etc., for a one-year period following
the provision of a covered hearing aid
The following are not covered:
•Batteriesorotherancillaryequipment,except
those covered under the terms of the initial
hearing aid purchase
Health Education Services
•Chargesforahearingaidthatexceeds
specifications to correct hearing loss
Information, including:
•Replacementpartsforhearingaids
•Hearingaidrepairaftertheone-yearwarranty
has expired
•Howtoeffectivelyuseyourhealthcareservices
•Healthbehavior
•Hearingaidreplacementmorethanonce
every 36 months
•Selfcare
•Tobaccousepreventionandcessationservices
•Surgicallyimplantedhearingdevices(Please
contact your medical group for authorization
of hearing equipment.)
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Part 5
caregiver and the patient’s family. Only an entity
licensed under the California Hospice Licensure
Act of 1990 or a licensed home health agency
with federal Medicare certification may provide
hospice services, except the hospice may arrange
with appropriately licensed individuals or other
entities to provide hospice services.
Home Health Care
Health services provided at the home by health
care personnel. Includes visits by registered nurses,
licensed vocational nurses and home health aides;
physical, occupational and speech therapy; and
respiratory therapy when prescribed by a licensed
practitioner acting within the scope of his or her
licensure.
Hospice services include a specific list of services.
Please see below. If you elect hospice services for
a terminal disease, you also will be entitled to
services from your attending physician, if he or she
is not an employee of the hospice, and to services
provided through the hospice. If you make a
hospice election, you may revoke it at any time.
Home health services are limited to those services
that are prescribed or directed by the attending
physician or other appropriate authority designated
by Anthem Blue Cross. If a basic health service
can be provided in more than one medically
appropriate setting, it is within the discretion of the
attending physician or other appropriate authority
designated by Anthem Blue Cross to choose the
setting for providing the care. Anthem Blue Cross
shall exercise prudent medical case management
to ensure that appropriate care is rendered in the
appropriate setting. Medical case management
may include consideration of whether a particular
service or setting is cost-effective when there is
a choice among several medically appropriate
alternative services or settings.
•Interdisciplinaryteamcarewithdevelopment
and maintenance of an appropriate plan of
care. An interdisciplinary team is a hospice
care team that includes the patient, the
patient’s family, a physician, a registered
Hospice
This coverage is for an individual who has a
terminal disease or a terminal illness. This means
someone who is not expected to live for more
than one (1) year and who chooses this type of
care. The decision to enter hospice can be changed
at any time.
Hospice services mean palliative care and care to
alleviate physical, emotional, social and spiritual
discomforts for a patient in the last phases of life
if the patient has a terminal disease. They also
include supportive care for patient’s primary
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
nurse, a social worker, a volunteer and a
spiritual caregiver. A plan of care is a written
plan that addresses the patient’s needs and the
needs of the family admitted to the hospice
program.
positive aspects and opportunities for growth.
These services also include dietary counseling
when needed.
•Medicaldirection.Thismeansconsultations
by a physician with the interdisciplinary team
and the patient’s attending physician with
regard to pain and symptom management.
This physician also will act as a liaison with
other physicians in the community.
• Skillednursingservices,certifiedhomehealth
aide services, and homemaker services under
the supervision of a qualified registered nurse.
Skilled nursing services include:
•Volunteerservices.Thismeansservices
provided by trained hospice volunteers to
provide support and companionship to the
patient and family during the remaining days
of the patient’s life and to the patient’s family
after her death.
– Palliative, supportive services required by a
patient with a terminal illness.
– Assessment, evaluation and case
management of the patient’s medical
nursing needs, the performance of
prescribed medical treatment for pain and
symptom control, emotional support for the
patient and her family, and the instruction
of caregivers in providing personal care to
the patient.
•Short-terminpatientcare.
•Prescriptiondrugsanddurablemedical
equipment and supplies, to the extent
reasonable and necessary for the palliation
and management of the terminal illness and
related conditions.
– Home health aide services mean services
provided for the personal care of a
terminally ill patient and related tasks in
the patient’s home under the plan of care to
increase the level of comfort and maintain
personal hygiene and a safe, healthy
environment for the patient.
– Homemaker services mean services to help
the patient maintain a safe and healthy
environment and to help the patient carry
out the treatment plan.
•Bereavementservices.Thismeansservicesfor
the patient’s surviving family members for at
least one year after the patient’s death.
•Socialservices/counselingservices.Thismeans
counseling and spiritual services to help
the patient and his or her family minimize
stress and problems by using appropriate
community resources and to maximize
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Part 5
•Physicaltherapy,occupationaltherapy,
and speech language pathology services for
symptom control or to allow the patient to
maintain activities of daily living and basic
function skills.
Hospital Services
In California, you can go to any hospital that
your PCP refers you to as long as the hospital has
a contract with Anthem Blue Cross.
In an emergency, you can go to any hospital
without an OK by Anthem Blue Cross. You or
your doctor must call Anthem Blue Cross within
48 hours, or as soon as reasonably possible, if
you are admitted to a hospital in an emergency
situation. All other inpatient hospital services and
some outpatient care will need an OK by your
medical group.
Anthem Blue Cross will make hospice services
available on a 24-hour basis to the extent
necessary to meet the needs of individuals for care
that is reasonable and necessary for the palliation
and management of the terminal illness and
related conditions.
A period of crisis is a period in which a patient
requires continuous care to achieve palliation or
management of acute medical symptoms. During
a period of crisis, Anthem Blue Cross will:
If you have surgery for breast cancer (mastectomy
or lymph node dissection), you and your doctor
decide how long you will need to stay in the
hospital after surgery. Anthem Blue Cross covers
this stay, and all needed care or problems that
may occur from this surgery.
•Makenursingcareavailableonacontinuous
basis for as much as 24 hours a day during
periods of crisis as necessary to maintain the
patient at home.
Hospital Services (Inpatient)
•Covershort-terminpatientcarearrangements
Requires prior authorization (except for
when the interdisciplinary team decides
childbirth and mastectomy-related services)
inpatient skilled nursing care that cannot be
provided in the home is required.
We cover hospital services received in a room with
two or more beds, common furniture, common
•Coverhomemakerorhomehealthaide
tools, routine nursing care and meals (including
services or both on a 24-hour continuous
special diets when medically necessary). We will
basis during periods of crisis, but the care
cover a private room when the hospital offers only
provided during these periods must be
this type of room as the basic room. This benefit
predominantly nursing care.
includes all other medically necessary services,
• Respitecare.Thismeansshort-terminpatient
including, but not limited to these:
care provided only when necessary to
• Careinspecialunits(includingintensivecare)
relieve the family members or other persons
caring for the patient. Anthem Blue Cross
• Operatingrooms,deliveryroomsandspecial
will make respite care available only on an
treatment rooms
occasional basis and for no more than five (5)
consecutive days at a time.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
Exclusions
•Suppliesandserviceslikelaboratory,
cardiology, pathology and radiology
Personal or comfort items or a private room in a
hospital are excluded unless medically necessary.
Services of dentists or oral surgeons are excluded
for dental procedures with the exception of
orthodontic services that are an integral part of
reconstructive surgery for cleft palate.
•Drugsandmedicinesthehospitalgivesyou
during your stay, including oxygen
•Bloodtransfusionsincludingbloodproducts
•Radiationtherapy,chemotherapyanddialysis
treatment
•Generalnursingcareandspecialdutynursing
as medically necessary
Hospital Services (Outpatient)
•Biologicalsandanesthesia
We cover services to diagnose an illness, to treat an
illness and to perform surgery at a hospital or an
outpatient facility. We cover these:
•Respiratorytherapy,andotherdiagnostic,
therapeutic and rehabilitative services as
appropriate
•Ancillaryservices,suchasphysicaltherapy,
occupational therapy, speech and language
pathology services and nutritional and dietary
counseling
•Inpatientcareinconnectionwithdental
procedures when hospitalization is required
because of an underlying medical condition
and clinical status or because of the severity of
the dental procedure
•Useoftheemergencyroom
•Operatingroomsandtreatmentrooms
• Generalanesthesiaformedicallynecessary
services
•Hospitalservicesthatreasonablycanbe
provided on an ambulatory basis including
related supplies and services like laboratory,
cardiology, pathology and radiology
charges in connection with dental procedures
when hospitalization is necessary because of
an underlying medical condition or clinical
status or because of the severity of the dental
procedure. (This benefit is only available
to members under seven years of age; the
developmentally disabled, regardless of age;
and members whose health is compromised
and for whom general anesthesia is medically
necessary, regardless of age. Anthem Blue Cross
will coordinate the services with the member’s
dental plan.)
•Drugsandmedicinesthehospitalgivesyou
during your stay, including oxygen
•Bloodtransfusionsincludingbloodproducts
•Servicesinconjunctionwithdentalprocedures
when the use of a hospital or outpatient facility
is required because of an underlying medical
condition and clinical status or because of the
severity of the dental procedure
• Generalanesthesiaformedicallynecessary
services
•Coordinationofdischargeplanning,including
the planning of such continuing care as may
be necessary
charges, and outpatient services in connection
with dental procedures when the use of a
hospital or surgery center is necessary because
of an underlying medical condition or clinical
•Physicaltherapy,occupationaltherapyand
speech therapy
•DiagnosticlaboratoryandX-rayservices
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Part 5
status or because of the severity of the dental
procedure. This benefit is only available
to members under seven years of age; the
developmentally disabled, regardless of age;
and members whose health is compromised
and for whom general anesthesia is medically
necessary, regardless of age. Anthem Blue Cross
will coordinate the services with the member’s
dental plan.
You have the right to stay in the hospital for at
least 48 hours for a vaginal delivery or for at least
96 hours for a cesarean section delivery. Any
earlier discharge of a mother and her newborn
child from the hospital must be made by the
attending provider in consultation with the
mother. If after consulting with you, your doctor
decides to discharge you before the 48- or 96
hour time period, Anthem Blue Cross will cover
a post-discharge follow-up visit within 48 hours
of discharge when prescribed by your doctor.
The visit includes parent education, assistance
and training in breast or bottle feeding and the
performance of any necessary maternal or neonatal
physical assessments. The doctor and you will
decide whether the post-discharge visit will occur
in the home, at the hospital, or at the doctor’s
office depending on the best solution for you.
•Radiationtherapy,chemotherapyanddialysis
treatments
Exclusions
Personal or comfort items or a private room in a
hospital are excluded unless medically necessary.
Services of dentists or oral surgeons are excluded
for dental procedures with the exception of
orthodontic services that are an integral part of
reconstructive surgery for cleft palate.
Maternity Care
Medically necessary professional and hospital
services relating to maternity care.
Covered services include these:
•Prenatalandpostpartumcare,including
complications of pregnancy
• Newbornexaminationsandnurserycarewhile
the mother is hospitalized
•Participationinthestatewideprenatal
testing program administered by the State
Department of Public Health known as the
Expanded Alpha Feto Protein Program
• Prenataldiagnosisofgeneticdisordersofthe
fetus by means of diagnostic procedures in
cases of high-risk pregnancy
• Counselingfornutrition,healtheducation
and social support needs
TTY: 1-888-757-6034
• Laboranddeliverycare,includingmidwifery
services
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
Mental Health Care Services
(Inpatient)
Limitations
Serious Emotional Disturbance (SED) Services
Mental health care in a participating hospital
when ordered and performed by a participating
mental health professional.
Diagnosis and treatment of SED conditions.
Inpatient mental health care services for the
treatment of a Serious Emotional Disturbance.
Examples of SED include, but are not limited to:
Mental Health Care Services (Provided by
Anthem Blue Cross or an Anthem Blue Cross
sub-contractor)
Unlimited days.
• Seriousproblemseatingorsleeping
• Oftencryingorsad
Diagnosis and treatment of a mental health
condition
• Sayingthingsthatworryyou
• Behavinginwaysthatcauseseriousfamily
and school problems
Limitations
Basic mental health care services are limited
to thirty (30) days per benefit year. Additional
days may be authorized by Anthem Blue Cross.
Anthem Blue Cross, with the agreement of the
member or applicant or other responsible adult
if appropriate, may substitute for each day of
inpatient hospitalization any of the following:
• Ongoingorfrequentproblemswithfriends
• Purposefullyhurtingherselfandothers
Limitations
Unlimited days
•2daysofresidentialtreatment
Mental Health Care Services
(Outpatient)
•3daysofdaycaretreatment
Requires prior authorization (No copayment)
•4outpatientvisits
Mental health care services when ordered and
performed by a participating Anthem Blue Cross
mental health provider
Severe Mental Illness (SMI)
treatment of Severe Mental Illnesses (SMI):
Mental health care services
• Treatmentformemberswhohaveexperienced
family dysfunction or trauma, including child
abuse and neglect, domestic violence, substance
abuse in the family, divorce or bereavement.
• Schizophrenia
• Schizoaffectivedisorder
• Bipolardisorder(manic-depressiveillness)
•Involvementoffamilymembersinthe
treatment to the extent the provider
determines it is appropriate for the health and
recovery of the member.
• Majordepressivedisorders
• Panicdisorder
• Obsessive-compulsivedisorder
• Pervasivedevelopmentaldisorderorautism
• Anorexianervosa
• Bulimianervosa
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Part 5
Limitations
Limitations
Basic mental health care outpatient health care
services are limited to twenty (20) visits per
benefit year, except that the number of treatment
days may be increased when outpatient treatment
days are substituted for inpatient hospitalization
days as described in the Inpatient Mental Health
care Services benefit description section of this
Evidence of Coverage (EOC) booklet.
Unlimited visits
Nutrition Services
(Except for diabetes)
Nutrition services, including nutritional
assessment for direct care and treatment of an
illness (except for diabetes).
Orthotics and Prosthetics
Outpatient mental health care services for the
treatment of Severe Mental Illnesses (SMI):
Includes medically necessary replacement
prosthetic and orthotic devices as prescribed by a
licensed practitioner acting within the scope of his
or her licensure
• Schizophrenia
• Schizoaffectivedisorder
•Initialandsubsequentprostheticdevices
(Require prior authorization)
• Panicdisorder
•Installationaccessoriestorestoreamethod
of speaking associated with a laryngectomy
(Require prior authorization)
• Anorexianervosa
• Bulimianervosa
•Prostheticdevicestorestoreandachieve
symmetry after a mastectomy (including, but
not limited to lumpectomy)
Limitations
Unlimited visits.
Contact Anthem Blue Cross’ Customer Service
at 1-877-687-0549 to determine whether you
should rent or buy. Certain items may be rented
up to the purchase price. If you have hearing
1-888-757-6034.
Serious Emotional Disturbance (SED) Services
Diagnosis and treatment of SED conditions.
treatment of a Serious Emotional Disturbance.
Examples of SED include, but are not limited to:
• Seriousproblemseatingorsleeping
• Oftencryingorsad
• Sayingthingsthatworryyou
• Behavinginwaysthatcauseseriousfamily
and school problems
TTY: 1-888-757-6034
• Ongoingorfrequentproblemswithfriends
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
• Purposefullyhurtingherselfandothers
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Part 5
Excluded items include, but are not limited to:
•Correctiveshoesandarchsupports(except
for therapeutic footwear and inserts for
individuals with diabetes)
Prescriptions
Some drugs require an OK from Anthem
Blue Cross
• Nonrigiddevicessuchaselastickneesupports,
We cover medically necessary drugs when ordered
corsets, elastic (support) stockings and garter
by a licensed prescriber acting within the scope of
belts
licensure. This benefit includes, but is not limited
•Dentalappliances
to:
• Electronicvoice-producingmachines
•Outpatientdrugsavailablebyprescriptiononly
• Morethanonedeviceforthesamepartofthe
body
•Drugsusedforsmokingcessation
•Prescriptionprenatalvitamins
• Eyeglasses(exceptforeyeglassesorcontact
lenses medically necessary after cataract surgery)
•Prescriptionfluoridesupplements(included
with vitamins or independent of vitamins)
Phenylketonuria (PKU)
•Insulinandinsulinsyringes
Testing and treatment of PKU, including those
formulas and special food products that are
part of a diet prescribed by a licensed physician
and managed by a health care professional in
consultation with a physician who specializes
in the treatment of metabolic diseases and who
participates in or is authorized by the plan,
provided that the diet is deemed medically
necessary to avert the development of serious
physical or mental disabilities or to promote
normal development or function as a consequence
of PKU.
•Needlesandpendeliverysystemsto
administer insulin
•Glucagon
•Lancets,bloodglucoseteststripsandketone
urine test strips in medically appropriate
quantities for use in monitoring diabetes
•Disposabledevicesthatarenecessaryforthe
administration of covered drugs, such as
spacers and inhalers for the administration
of aerosol prescription drugs and syringes for
self-injectable outpatient prescription drugs
that are not dispensed in prefilled syringes.
The term “disposable” includes devices that
may be used more than once before disposal.
Physical, Occupational and Speech
Therapy
•Prescriptioncontraceptivedrugsprescribed
for birth control (injectable contraceptive
drugs are covered under your medical benefit).
These medications may be prescribed,
as medically necessary, for other medical
conditions. Please refer to Part 8, How to Get
Prescription Drugs.
We may require periodic evaluations as long as
medically necessary therapy is provided.
• Rehabilitation,includingphysicaltherapy,
occupational therapy and speech therapy
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Part 5
• Allnoninfusedcompoundprescriptionsthat
contain at least one covered prescription
ingredient
•Formulasandspecialfoodproductsprescribed
by a physician or nurse practitioner for the
treatment of phenylketonuria (PKU)
•Self-injectablemedicationsandneedlesand
syringes for insulin injections are covered
under the pharmacy benefit (office-based
injectables and needles and syringes used for
other injectable drugs are covered under your
medical benefit or under capitation from your
physician)
•Prescriptiondrugsthatareadministeredwhile
a member is a patient or resident in a rest
home, nursing home, convalescent hospital
or similar facility when provided through an
Anthem Blue Cross network pharmacy. These
prescription drugs can be obtained by you,
a friend, relative or caregiver on your behalf
under your pharmacy benefit.
Preventive Health Services
• Yearlyexams(pelvicexam,Papsmearand
breast exam) and any other gynecological
service from your primary care provider or an
OB/GYN provider in the network (primary
care provider approval not required)
• Medicallyacceptedcancerscreeningtests
including, but not limited to breast and
cervical cancer screening, including a Human
Papillomavirus (HPV) screening
• Healtheducationservices,including
education regarding personal health behavior
and health care and recommendations
regarding the optimal use of health care
services and laboratory services appropriate for
such examinations.
• Immunizationsformothers,including
immunizations for adults as recommended by
the ACIP. Immunizations required for travel
as recommended by the ACIP. Immunizations
such as Hepatitis B for individuals at
occupational risk and other age appropriate
immunizations as recommended by the ACIP.
• FDA-approvedcervicalcancerscreeningtests
such as the Pap smear test and the office visit
that goes with those tests when ordered by
your doctor, registered nurse practitioner or
certified nurse midwife
Preventive services also include services for the
detection of asymptomatic diseases, including, but
not limited to:
• Newbornhospitalvisitsandhealth
• Avarietyofvoluntaryfamilyplanningservices
• Mammogramexaminationswhenorderedby
your participating physician, registered nurse
practitioner or certified nurse midwife
• Contraceptiveservices
• Prenatalcare
• Visionandhearingtesting
• Sexuallytransmitteddisease(STD)testing
• HumanImmunodeficiencyVirus(HIV)testing
• Cytologyexaminationsonareasonable
periodic basis
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
•Inpatientprofessionalservicesprovidedin
a licensed hospital, skilled nursing facility,
hospice or mental health facility
Professional Services
Some professional services require an OK from
Anthem Blue Cross
We cover medically necessary services and consults
with a doctor or other licensed health care
provider including these:
•Drugsandmedicinesthedoctorgivesyou
during your visit
Cancer Clinical Trials
• Servicesofaphysicianorotherlicensedhealth If you have cancer and belong to a Phase I, Phase
care provider acting within the scope of his or II, Phase III, or Phase IV cancer clinical trial:
her license
•AnthemBlueCrosswillcoverallroutine
•Servicesofananesthesiologistorananesthetist
health care costs related to the clinical trial the
same as any other medical condition.
•Outpatientdiagnosticradiologyand
laboratory services
•Yourmedicalgroupmustreferyouand
approve it.
•Officevisitsforhealthproblemsorinjuries,
including allergy tests and treatments;
respiratory care for breathing problems; and
other specialist visits
•Youmustbecaredforbyaparticipating
provider in California unless the clinical trial
is not offered at a California hospital or by a
California doctor.
•Homevisits
When a nonparticipating provider provides covered
•Cytologyexamsonareasonableperiodicbasis services for a clinical trial, Anthem Blue Cross will
pay that doctor a fee that has been agreed to by
•Eyeexaminationsandeyerefractions
Anthem Blue Cross and the doctor. However, you
•Healtheducation,includingtobaccouseand will have to pay for charges over that fee rate.
drug and alcohol abuse
Drugs used to treat your illness must be exempt
•Immunizations
•Nutritionservices,includingnutritional
assessments for direct care and treatment of an
illness (except for diabetes)
•Surgery,assistantsurgeryandanesthesia
(inpatient and outpatient), including
reconstructive surgery, unless a better option
exists or the surgery would make only a small
improvement. (Prior auth is not needed for
reconstructive surgery needed as a result of a
mastectomy.)
under federal regulation from a new drug
application or be approved by any of these agencies:
•NationalInstituteofHealth
•TheFoodandDrugAdministration
•TheU.S.DepartmentofDefense
•TheU.S.VeteransAdministration
Anthem Blue Cross will cover most common
services not provided by the clinical trial.
•Radiationtherapy,chemotherapy,dialysis
treatment and blood transfusions
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Part 5
These include:
Reconstructive Surgery
•Healthcareservicesnormallyprovidedabsent
a clinical trial
All reconstructive surgery, not mastectomy
related, requires prior authorization.
•Healthcareservicesrequiredforgettingthe
investigational drug, item, device or service
Anthem Blue Cross will cover reconstructive
surgery to the extent described below. Anthem
Blue Cross also will cover prosthetic devices or
reconstructive surgery related to a mastectomy to
the extent described below.
•Healthcareservicesrequiredfortheclinically
appropriate monitoring of the investigational
drug, item, device or service
•Healthcareservicesprovidedforpreventing
medical problems that may occur from using
the investigational drug, item, device or service
Anthem Blue Cross will cover medically necessary
reconstructive surgical services performed on
abnormal structures of the body caused by
congenital defects, developmental anomalies,
trauma, infection, tumors or disease and are
performed to improve function or create a normal
appearance to the extent possible. This benefit
includes reconstructive surgery to restore and
achieve symmetry due to mastectomy (including,
but not limited to lumpectomy). This includes
medically necessary dental or orthodontic services
that are an integral part of reconstructive surgery
for cleft palate procedures or services. Anthem
Blue Cross is ultimately responsible for providing
services.
•Healthcareservicesneededasaresultof
providing the investigational drug, item,
device or service, including finding or treating
complications
Anthem Blue Cross will not cover:
• Drugsordevicesthathavenotbeenapproved
by the Food and Drug Administration (FDA)
and that are associated with the clinical trial.
•Nonclinicalservicessuchastravel,housing,
companion costs or any other nonclinical
expense that you may need as a result of the
treatment being provided for purposes of the
clinical trial.
Anthem Blue Cross will not cover cosmetic
surgery. This means Anthem Blue Cross will not
cover surgery to alter or reshape normal structures
of the body to improve appearance.
•Anyitemorservicenotusedtomanageyour
health, such as anything provided solely for
data collection and analysis.
•Servicesprovidedinaclinicaltrialthatare
listed under Part 7, What Anthem Blue Cross
Does Not Cover.
•Servicescustomarilyprovidedbytheresearch
sponsors free of charge to you.
You will be financially responsible for the costs of
noncovered services.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 5
If you have a mastectomy or lymph node
dissection, Anthem Blue Cross will not require
prior authorization in determining the length of
your hospital stay following that procedure. In
addition, Anthem Blue Cross will cover:
Major Organ Transplants
We cover:
•Majororgantransplantsandbonemarrow
transplants, if medically necessary and not
experimental or investigational in nature.
If we do not cover a therapy because it is
experimental or investigational and you are
terminally ill, you may ask that another party
review our decision. We will arrange to have
an impartial, independent entity review our
decision in accordance with the requirements
of California law. See Part 9, Grievance
and Appeals Process under Independent
Medical Review for more information about
the independent medical review process.
•Prostheticdevicesorreconstructivesurgery,
including devices or surgery to restore and
achieve symmetry for you, related to the
mastectomy.
•Allcomplicationsfromamastectomy,
including lymphedema.
Skilled Nursing Facilities
This coverage is for up to 100 days each benefit
year. Services are covered when medically necessary,
prescribed by an Anthem Blue Cross provider or
nurse practitioner, and provided in a licensed skilled
nursing facility. The Anthem Blue Cross Provider
Directory lists the hospitals and skilled nursing
facilities that work with us.
•Reasonablemedicalandhospitalexpenses
of a donor or an individual identified as a
prospective donor if these expenses are directly
related to your transplant.
•Chargesfortestingofrelativesformatching
bone marrow transplants.
Covered services include, but are not limited to:
•Skillednursingona24-hourperdaybasis
•Chargesassociatedwiththesearchandtesting
of unrelated bone marrow donors through a
recognized Donor Registry.
•Bedandboard
•X-rayandlaboratorytests
• Chargesassociatedwiththesearchand
testing of unrelated bone marrow donors
through a recognized Donor Transplant Bank,
if the expenses are directly related to your
anticipated transplant.
•Respiratorytherapy
•Physicaltherapy,occupationaltherapyand
speech therapy
•Medicalsocialservices
•Prescribedmedications
•Chargesassociatedwiththeprocurementof
donor organs through a recognized Donor
Transplant Bank if the expenses are directly
related to your anticipated transplant.
•Medicalsupplies
•Appliancesandequipmentordinarily
furnished by the skilled nursing facility
32
Part 5
Urgent Care
Urgent care services are services needed to prevent
serious deterioration of your health resulting
from an unforeseen illness, an injury, prolonged
pain or a complication of an existing condition,
including pregnancy, for which treatment cannot
be delayed. Anthem Blue Cross covers urgent
care services. To be covered, urgent care service
must be needed because the illness or injury will
become much more serious if you wait for a
regular doctor’s appointment.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 6
Benefits Summary
This matrix is intended to be used to help you compare covered benefits and is a summary only. Check
Part 5, What Anthem Blue Cross Covers, for a detailed description of covered benefits and limitations.
This symbol means that prior authorization (an OK from Anthem Blue Cross) is needed for
Anthem Blue Cross to cover these services. All services must be medically necessary and obtained from
a provider in your network. You may obtain emergency services inside or outside your service area and
urgent care services outside your service area, from nonnetwork providers.
Benefits*
Services
Alcohol and drug abuse treatment (inpatient)
Hospitalization to remove toxic substances from the system.
Alcohol and drug abuse treatment (outpatient)
Crisis intervention and treatment of alcoholism or drug
abuse. Anthem Blue Cross offers at least 20 visits per
benefit year. Anthem Blue Cross may offer additional visits.
Ambulance services (Medical transportation services) Emergency ambulance transportation and nonemergency
transportation to transfer a member from a hospital to
Nonemergency transport requires an OK from
another hospital or facility or facility to home.
Anthem Blue Cross
Blood and blood products
Includes processing, storage and administration of blood
and blood products in inpatient or outpatient settings
Cataract spectacles and lenses
Cataract spectacles and lenses, cataract contact lenses or
intraocular lenses that replace the natural lens of the eye
after cataract surgery.
Chiropractic services
Limited to short term therapy
Clinical Cancer Trials
Coverage for a member’s participation in a cancer clinical
trial, phase I through IV, when the member’s physician has
recommended participation in the trial and the member
meets certain requirements.
Diabetic care
Equipment and supplies for the management and treatment
of insulin-using diabetics, non-insulin-using diabetics and
gestational diabetes as medically necessary, even if the items
are available without prescription.
Diagnostic X-ray and laboratory services
Laboratory services and diagnostic and therapeutic
radiological services necessary to appropriately evaluate,
diagnose and treat members.
Durable medical equipment
Custom-made durable medical equipment needs an
OK from Anthem Blue Cross
Medical equipment appropriate for use in the home which
primarily serves a medical purpose, is intended for repeated
use and is generally not useful to a person in the absence of
illness or injury.
Emergency health care services
24 hour emergency services are covered both in and out
of the Anthem Blue Cross service area and in and out of
Anthem Blue Cross’ participating facilities.
Family planning services
Voluntary family planning services.
Counseling and surgical procedures for sterilization, as
permitted by state and federal law.
Coverage for diaphragms and other federal Food and
Drug Administration-approved devices pursuant to the
prescription drug benefit.
Voluntary termination of pregnancy.
34
Part 6
Benefits Summary
Benefits*
Services
Health education
Includes education regarding personal health behavior and
health care and recommendations regarding the optimal use
of health care services.
Home health care services
Services provided at the home by health care personnel.
Hospice
For members who are diagnosed with a terminal illness and
who elect hospice care instead of traditional health care
services.
Hospital services (Inpatient)
Childbirth and mastectomy related services do not
require an OK from Anthem Blue Cross
Room and board, nursing care and all medically necessary
ancillary services.
Hospital services (Outpatient)
Emergency services do not require an OK from
Anthem Blue Cross
Diagnostic, therapeutic and surgical services performed at a
hospital or outpatient facility.
Maternity care
Professional and hospital services relating to maternity care.
Mental health care services (Inpatient)
Mental health care in a participating hospital when ordered
and performed by a participating mental health professional
for the treatment of a mental health condition.
• Diagnosisandtreatmentofamentalhealthcondition
• 30daysperbenefityear.AdditionaldaysmaybeOK’d
by Anthem Blue Cross
• AnthemBlueCross,withtheagreementofthe
member or other responsible adult if appropriate, may
substitute for each day of inpatient hospitalization any
of the following:
- 2 days of residential treatment
- 3 days of day care treatment
- 4 outpatient visits
• Inpatientmentalhealthcareservicesforthetreatment
of severe mental illnesses
• Unlimiteddays
Serious Emotional Disturbance (SED
• Inpatientmentalhealthcareservicesforthetreatment
of SED conditions
• Unlimiteddays
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Part 6
Benefits Summary
Benefits*
Mental health care services (Outpatient)
Serious Emotional Disturbance (SED)
Nutrition services
Orthotics and prosthetics
Phenylketonuria (PKU)
Physical, occupational and speech therapy
Prescriptions
Preventive health care services
Professional services
Some professional services need an OK from Anthem
Blue Cross
Services
Mental health care when ordered and performed
by a participating mental health professional
• Thisincludesthetreatmentofmemberswhohave
experienced family dysfunction or trauma, including
child abuse and neglect, domestic violence, substance
abuse in the family or divorce or bereavement
• Familymembersmaybeinvolvedinthetreatment
when medically necessary for the health and recovery
of the member
• 20visitsperbenefityear.Additionalvisitsmaybe
OK’d Anthem Blue Cross
• Outpatientmentalhealthcareservicesforthetreatment
of severe mental illnesses
• Unlimitedvisits
• Outpatientmentalhealthcareservicesforthetreatment
of SED conditions
• Unlimitedvisits
Direct member care nutrition services including nutrition
assessment.
Original and replacement devices as prescribed by a licensed
practitioner.
Testing and treatment for PKU
Therapy may be provided in a medical office or other
appropriate outpatient setting.
Drugs prescribed by a licensed practitioner
Periodic health examinations including all routine
diagnostic testing and laboratory services, eye examinations,
hearing tests, hearing aids and services, immunizations and
services for the detection of asymptomatic diseases.
Services and consultations by a ohysician physician or other
licensed health care provider.
Reconstructive surgery
Reconstructive surgery related to a mastectomy
(including, but not limited to lumpectomy) does not
require an OK from Anthem Blue Cross
Performed on abnormal structures of the body caused
by congenital defects, developmental anomalies, trauma,
infections, tumors or disease and are performed to improve
function or create a normal appearance. Covers cleft palate.
Skilled nursing care
Services provided in a licensed skilled nursing facility.
Major organ transplants
Coverage for organ transplants and bone marrow
transplants which are not experimental or investigational.
No deductibles will be charged for covered benefits.
No lifetime maximum limits on benefits apply under this
plan.
Deductibles
Lifetime maximums
*Benefits are provided only for services that are medically necessary.
36
Part 7
What Anthem Blue Cross Does Not Cover
Here are the kinds of care Anthem Blue Cross
cannot give to you. These benefits are excluded
for infants born to AIM subscribers. Infants born
to AIM subscribers are automatically eligible
for enrollment in the Healthy Families Program
(HFP). Please refer to Health Care Coverage for
Infants on the page before the Table of Contents
in the EOC.
• Servicesofthedentistororalsurgeonfor
dental procedures
• Damagetonaturalteethcausedbychewingor
biting
• Hospitalstaysforthepurposeofadministering
general anesthesia, when the general anesthesia
is not considered medically necessary
Home Health Care
The services listed below are not covered under
the Anthem Blue Cross plan. If you have any
questions about what is not covered, call us
at 1-877-687-0549. If you have hearing or
1-888-757-6034.
Excluded home health care items include, but are
not limited to these:
• Servicesfromagenciesotherthanacertified
Home Health Agency or Visiting Nurse
Association
Any service or item not listed as being covered
may not be a benefit.
• Servicesforyourpersonalcare,suchashelp
in walking, bathing, dressing, feeding or
preparing food
Dental Care
• Custodialcare
Excluded dental care items include, but are not
limited to these:
• Bracesorotherappliancesorservicesfor
straightening the teeth (orthodontic services)
• Dentures,bridges,crowns,caps,orother
dental services, treatment of the teeth or
gums, or having teeth pulled, except for care
given if teeth are accidentally injured
• Dentalimplantsorimplantremoval
• Servicesorsuppliesforanykindoftreatment
of the joint of the jaw (including treatment for
temporomandibular joint problems) or the way
the upper and lower teeth meet (except when
medically necessary). This language shall not
be construed to exclude surgical procedures for
any condition directly affecting the upper or
lower jawbone or associated bone joints.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 7
Implants
•Electronicvoice-producingmachines.
Except cardiac pacemakers, intraocular lenses,
screws, nuts, bolts, bands, nails, plates and pins
used for the fixation of fractures or osteotomies
and artificial knees and hips.
•Morethanonedeviceforthesamepartofthe
body.
•Devicesthatdonothaveamedicalpurpose.
•Modificationstothehomeorcar.
Excluded are cochlear implants and other
surgical implants determined to be experimental
and/or not medically necessary. Please refer
to Part 9, Grievance and Appeals Process,
sections “Independent Medical Review” and
“Independent Medical Review for Denials of
Experimental/Investigational Therapies” if
your request for services was denied because it
was determined to be not medically necessary or
experimental.
•Deluxeequipment.
Other Services
Other excluded services include, but are not
limited to:
•Servicesreceivedbeforethesubscriber’s
effective date of coverage.
•Servicesreceivedafterthesubscriber’sor
eligible family member’s coverage ends.
•Anyservicesorsuppliesthatarenotmedically
necessary.
Medical Equipment and Supplies
Anthem Blue Cross does not cover medical
equipment and supplies that are:
•Careyoureceivedfromanon-Anthem
Blue Cross AIM health care provider except
when emergency or urgently needed services
are needed, or as authorized by Anthem
Blue Cross.
•Usedonlyforyourcomfort,convenienceor
hygiene.
•Usedforexercise.
•Usedonlyformakingtheroomorhome
comfortable, such as air conditioning, air
filters, air purifiers, exercise equipment, spa,
swimming pools, elevators and supplies for
hygiene or looks.
•Thosemedical,surgical(includingimplants)
or other health care procedures, services,
products, drugs or devices which are:
- Experimental or investigational.
•Disposablesuppliesexceptostomybags,
urinary catheters and supplies consistent with
Medicare coverage guidelines
- Not recognized in accord with generally
accepted medical standards as being safe
and effective for use in the treatment in
question.
•Experimentalorresearchequipment.
- Outmoded or not effective.
•Morethanonepieceofequipmentthatserves
the same function.
•AnyservicesnotOK’dbyyourmedical
group when an OK by your medical group
is required. See Part 1, How to Use Your
Anthem Blue Cross HMO Health Plan,
section “Prior Authorization (an OK by
Anthem Blue Cross or your Medical Group
or PCP).”
•Correctiveshoesandarchsupports(exceptfor
therapeutic footwear for diabetics).
•Nonrigiddevicessuchaselasticknee
supports, corsets, elastic (support) stockings
and garter belts.
•Dentalappliances.
38
Part 7
•Anyservicesoritemsspecificallyexcludedin
Part 5, What Anthem Blue Cross covers.
•Drugsthatyougetinanothercountry,unless
related to a medical emergency or urgent care.
• Anyservicesyoureceivedthatareeligiblefor
reimbursement by insurance or are covered
under any other insurance or health plan.
If you are covered by another health plan,
that plan will pay first and Anthem Blue Cross
will pay second. The total of the two
payments cannot be more than the total
amount allowed by Anthem Blue Cross. Call
us at 1-877-687-0549 for more information.
If you have hearing or speech loss, you may
call our TTY line at 1-888-757-6034.
• Drugsusedtostimulatehairgrowth.
•Vitaminsexceptforprescriptionprenatal
vitamins and vitamins with fluoride.
•Patentorover-the-countermedicines,
including nonprescription contraceptive
jellies, ointments, foams, condoms, etc.
•Medicinesnotrequiringawrittenprescription
order except for insulin and smoking cessation
drugs.
•Emergencyfacilityservicesfornonemergency
conditions except services to stabilize the
member or for medical screening examination
if the member reasonably believed an
emergency existed.
• Careyoureceivedforahealthproblemthat
was work-related, if the care was paid for
under the Worker’s Compensation law or a
similar law. If such other coverage is available,
Anthem Blue Cross will provide benefits
under this program subject to its right to a
lien or other recovery under applicable law.
•Transportationbyairplane,passengercar,taxi,
or other form of public conveyance.
• Servicesyouactuallyreceivethatareprovided
by a local, state or federal government agency
if you are not legally required to pay for them,
except when federal or state law expressly
requires Anthem Blue Cross to pay for them.
Anthem Blue Cross will pay for services
provided at Veterans Administration Hospitals
and military treatment facilities to the extent
required by law.
•ServicesorcarecoveredbyMedicare,ifyou
are enrolled in Medicare.
•Personalorcomfortitemsoraprivateroomin
a hospital, unless medically necessary.
•Eyeglassesorcontactlenses,exceptthose
eyeglasses or contact lenses medically
necessary after cataract surgery with insertion
of an intraocular lens as stated in Part 5,
What Anthem Blue Cross Covers.
•Eyeexercisesandorthoptics.
•Telephoneorfacsimileconsultations.
•Dietarysupplementsexceptfortreatmentof
PKU.
•Syringesorneedlesthatarenotprescribedby
your doctor.
•Drugsthatareforcosmeticorbeautypurposes,
and are not otherwise medically necessary.
•Weightlossservices,programsorsupplies,
except for medically necessary treatment of
morbid obesity.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 7
Review (IMR) process. See Part 9, Grievance
and Appeals Process for more information
about IMR.
Pregnancy and Maternity Care
Excluded services include, but are not limited to:
•Fertilitytreatments,suchasartificial
insemination and in vitro fertilization.
•Drugsforcosmeticpurposesthatarenot
otherwise medically necessary.
•Diagnosisofinfertility,unlessdonein
conjunction with covered gynecological
services.
•Patentorover-the-counter(OTC)drugs,
including contraceptive jellies, ointments,
foams and condoms.
• MaternitycareforaPaidSurrogateMother
who enrolled in the program with an effective
date on or after February 1, 2012
•Drugsthatdonotrequireawritten
prescription except for insulin and smoking
cessation drugs.
Prescription Drugs
•Dietarysupplementsexceptforformulas
or special food products used to treat
phenylketonuria or PKU.
Excluded prescription drugs include, but are not
limited to:
•Medicinethatwasnotobtainedfroman
Anthem Blue Cross network pharmacy
except in an emergency or as emergency
contraception.
•Experimentalorinvestigationaldrugs,unless
accepted for use by the standards of the
medical community. If your doctor requests
prior authorization for an experimental or
investigational drug and the request is denied
by Anthem Blue Cross, you may appeal the
decision through the Independent Medical
•Medicinethatwasobtainedfromapharmacy
outside of your service area, unless it’s an
emergency, including urgently needed services
when you are outside your service area, or
emergency contraception.
•Brandnamedrugsthathavegeneric
equivalents are not covered, unless WellPoint
Pharmacy Management approves your
physician’s request for prior authorization.
Your physician must request prior
authorization by calling Express Scripts
Inc.,(ESI) at 1-800-417-8164 or faxing to
Prior Authorization at 1-800-357-9577.
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Part 7
Professional Services
Skilled Nursing Facilities
Excluded professional services include, but are not
limited to these:
Excluded skilled nursing facilities services include,
but are not limited to:
• Acupuncture
• Routinephysicalexamsaskedforbyajob,
school camp or sports program
• Careforotherthanamedicalneedforskilled
nursing care, such as help with personal care,
like bathing or feeding.
• Footcarelikenailtrimmingexceptwhen
medically necessary podiatric medical care
• Careformorethan100daysperbenefityear
in a licensed facility.
• Cosmeticsurgerydonetochangeorreshape
normal body parts so that they look better
• Custodialcare.
• Eyesurgeryjustforcorrectingvision(like
near-sightedness)
• Weightlossservices,programsorsupplies,
except for medically necessary treatment of
morbid obesity
This exclusion does not apply to:
– Reconstructive surgery to correct or repair
abnormal structures of the body caused
by congenital defects, developmental
abnormalities, trauma, infection, tumors or
disease, to the extent it is possible to improve
function or create a normal appearance.
– Prosthetic devices or reconstructive surgery,
including devices or surgery to restore and
achieve symmetry for you, related to a
mastectomy.
– When complications exceed routine
follow-up care, such as life-threatening
complications of cosmetic surgery.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 8
How to Get Prescription Drugs
Benefits are provided as follows for prescription
drugs obtained from licensed network pharmacies
or through our mail service prescription drug
program Express Scripts Inc. (ESI) by members
who are eligible to receive outpatient prescription
drugs under this Combined Evidence of Coverage
and Disclosure Form.
What Can My Doctor Prescribe?
Anthem Blue Cross uses a “Preferred Drug List
(PDL).” This is a list of brand-name and generic
prescription drugs and supplies preferred by
Anthem Blue Cross for the first line of drug therapy.
Just because a prescription drug or supply is on the
PDL does not guarantee that your doctor will order
it for a certain condition. A group of doctors and
pharmacists updates this list of drugs every three
months. Updating this list helps ensure that the
drugs on it are safe and useful. If your doctor thinks
you need to take a drug that is not on this list, your
doctor can request a prior authorization. If you
would like to know if a drug is on this list or for a
copy of the Anthem Blue Cross PDL, please call
ESI at 1-866-297-1013. If you have hearing or
speech loss, you may call the ESI TTY line at
1-800-905-9821. You can also visit www.anthem.
com/ca. Only your doctor can decide which drug is
best for you.
Generic drugs will be dispensed by network
pharmacies. Brand name drugs that have generic
equivalents are not covered, unless WellPoint
Pharmacy Management approves your physician’s
request for prior authorization. Please call
Express Scripts Inc. (ESI) Prior Authorization at
1-800-417-8164 or fax to Prior Authorization
at 1-800-357-9577 if you have a question about
prior authorization.
medical condition. A 72-hour emergency supply
of medication may be dispensed to the member
by the pharmacist if he/she determines it is
appropriate, and Anthem Blue Cross will reimburse
the pharmacy for that emergency supply. If the
request for prior authorization is denied, you will
receive a letter of explanation with the reasons for
disapproval and any alternative drug or treatment
offered. If you have a concern with services from
Anthem Blue Cross, call one of our Anthem
Blue Cross representatives at 1-877-687-0549.
If you have hearing or speech loss, you may call
our TTY line at 1-888-757-6034. You can also
file a grievance to get an answer on any concern
that you are having with Anthem Blue Cross,
including appealing the denial of a request for prior
authorization. We can mail a grievance form to you
to fill out and return. For additional information,
see Part 9, Grievance and Appeals Process.
Certain drugs are not recommended to be
interchanged once they have been started. These
are called Narrow Therapeutic Index (NTI) drugs.
Regardless of their PDL status or the availability
of generic equivalents, NTI drugs will be covered
under the prescription drug benefit without
the physician indicating “do not substitute” or
“dispense as written.” A list of applicable NTI
drugs is available by calling WellPoint Pharmacy
Management at 1-866-297-1013. If you have
hearing or speech loss, you may call the
Wellpoint Pharmacy Management TTY line at
1-800-905-9821.
Anthem Blue Cross will cover a prescription drug
for use other than its FDA-approved use if:
•TheFDAhasapprovedthedrug.
•Thedrugismedicallynecessarytotreata
covered medical condition.
We will review and decide upon requests for
prior authorization within one (1) business day
or longer, based upon the nature of the member’s
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Part 8
How to Get Prescription Drugs
• Thedrughasbeenrecognizedfortreatment
of that condition in peer reviewed medical
literature.
Prescription Drugs
For purposes of this benefit, insulin and
prescription prenatal vitamins will be deemed
prescription drugs.
When you get your prescription filled at an
Anthem Blue Cross network pharmacy, you will
be given a 30-day supply of medicine. You may
get refills if your doctor wrote your prescription
with refills. Usually the pharmacy will call your
doctor to check if refills can be given. For more
information on covered prescription drugs, see
Part 5, What is Anthem Blue Cross Covers
under “Prescriptions”.
Where to Get Your Prescriptions Filled
Maintenance Drugs
You must obtain your prescription drugs from an
Anthem Blue Cross network pharmacy. You can
locate an Anthem Blue Cross network pharmacy
by calling drug stores located near you and asking
them if they accept Anthem Blue Cross. Your
medicine will not be covered if you go to a drug
store that is not an Anthem Blue Cross network
pharmacy. If it’s an emergency and you can’t go
to an Anthem Blue Cross network pharmacy, go
to the nearest drug store and have them call us
at 1-877-687-0549. Your medicine will not be
covered if you go to a drug store outside of your
service area, unless it’s an emergency, including
urgently needed services when you are outside of
your service area.
Maintenance drugs are drugs that you take for
longer than a month, such as contraceptives, or
drugs prescribed for chronic conditions such as
diabetes, thyroid problems, asthma or seizure
disorders.
Anthem Blue Cross checks the medications
you are getting with your Anthem Blue Cross
coverage. Some drugs can be harmful if taken
together.
If you decide to get your maintenance drug at
an Anthem Blue Cross network pharmacy, you
will receive a 30-day supply. You can get up to
a 60-day supply of a maintenance drug through
our Mail Service Prescription Drug Program,
Express Scripts Inc. Your doctor must write the
prescription for no more than a 60-day supply
with up to five refills.
You may call the Mail Service Prescription Drug
Program at 1-866-274-6825 if you have any
questions or need an enrollment/order form.
If you need emergency contraception, you may
receive it from an Anthem Blue Cross network
pharmacy. Anthem Blue Cross also covers
emergency contraception from a non-network
pharmacy in a medical emergency.
You can call us at 1-877-687-0549 if you need
help finding a drug store near you or have any
questions about your pharmacy benefits. If you
have hearing or speech loss, you may call our TTY
line at 1-888-757-6034.
TTY: 1-888-757-6034
In emergencies, go to the nearest drug store and
have them call us at 1-877-687-0549.
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 9
Grievance and Appeals Process Our commitment to you is to ensure not only
quality of care, but also quality in the treatment
process. This quality of treatment extends
from the professional services provided by plan
providers to the courtesy extended you by our
telephone representatives.
If you have questions about the services you
receive from a plan provider, we recommend that
you first discuss the matter with your doctor. If
you continue to have a concern regarding any
service you received, call Anthem Blue Cross’
Customer Service at 1-877-687-0549. If you
have hearing or speech loss, you may call our TTY
line at 1-888-757-6034.
Grievance
You may file a grievance with Anthem Blue Cross
at any time. You can obtain a copy of Anthem
Blue Cross’ Grievance Policy and Procedure
by calling our Customer Service number at
1-877-687-0549. If you have hearing or
1-888-757-6034. To begin the grievance process,
you can call, write, or fax the plan at:
ANTHEM BLUE CROSS
PO BOX 60007
LOS ANGELES, CA 90060-0007
Phone number: 1-877-687-0549
Fax number: 1-888-716-5183
You can also use our website at anthem.com/ca
Click on Members.
Anthem Blue Cross will acknowledge receipt of
your grievance within five (5) days and will resolve
your grievance within thirty (30) days. If your
grievance involves an imminent and serious threat
to your health, including but not limited to severe
pain, potential loss of life, limb, or major bodily
function, you or your doctor may request that
Anthem Blue Cross expedite its grievance review.
Anthem Blue Cross will evaluate your request
for an expedited review, and, if your grievance
qualifies as an urgent grievance, we will resolve
your grievance within three (3) days from the
receipt of your request.
You are not required to file a grievance with
Anthem Blue Cross before asking the Department
of Managed Health Care (DMHC) to review your
case on an expedited review basis. If you decide to
file a grievance with Anthem Blue Cross in which
you ask for an expedited review, Anthem Blue Cross
will immediately notify you in writing that:
1. You have the right to notify the DMHC about
your grievance involving an imminent and
serious threat to health,
44
Part 9
Grievance and Appeals Process 2. We will respond to you and the DMHC with
a written statement on the pending status or
disposition of the grievance no later than 72
hours from receipt of your request to expedite
review of your grievance.
•Thedisputedhealthcareservicehasbeen
denied, modified, or delayed by Anthem
Blue Cross or one of its plan doctors, based in
whole or in part on a decision that the health
care service is not medically necessary.
Cultural and Linguistic Complaints
•YouhavefiledagrievancewithAnthem
Blue Cross and the disputed decision was
upheld or the grievance remains unresolved
after thirty (30) calendar days.
If you think Anthem Blue Cross did not meet
your cultural and linguistic needs, please call
us at 1-877-687-0549. If you have hearing
1-888-757-6034. You are entitled to receive free
interpreter services.
If your grievance qualifies for expedited review,
you are not required to file a grievance with
Anthem Blue Cross prior to requesting an IMR.
Also, the DMHC may waive the requirement that
you follow Anthem Blue Cross’ grievance process
in extraordinary and compelling cases.
Independent Medical Review
If medical care that is requested for you is denied,
delayed, or modified by Anthem Blue Cross
or a plan provider, you may be eligible for an
Independent Medical Review (IMR). If your
case is eligible and you submit a request for an
IMR to the Department of Managed Health
Care (DMHC), information about your case
will be submitted to a medical specialist who will
review the information provided and make an
independent determination on your case. You will
receive a copy of the determination. If the IMR
specialist so determines, Anthem Blue Cross will
provide coverage for the health care services.
For cases that are not urgent, the IMR
organization designated by the DMHC will
provide its determination within thirty (30) days
of receipt of your application and supporting
documents. For urgent cases involving an
imminent and serious threat to your health,
including but not limited to severe pain, potential
loss of life, limb, or major bodily function, the
IMR organization will provide its determination
within three (3) business days. At the request of
the experts, the deadline can be extended up to
three (3) days if there is a delay in obtaining all
necessary documents.
An IMR is available in the following situations:
The IMR process is in addition to any other
procedures or remedies that may be available to
you. A decision not to participate in the IMR
•Youhavereceivedurgentcareoremergency
process may cause you to forfeit any statutory
services that a doctor determined was
right to pursue legal action against the plan
regarding the care that was requested. You pay no
•Youhavebeenseenbyanin-plandoctorforthe application or processing fee for an IMR.
diagnosis or treatment of the medical condition
for which you seek independent review.
•Yourdoctorhasrecommendedahealthcare
service as medically necessary.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 9
Grievance and Appeals Process You have the right to provide information in
support of your request for IMR. For more
information regarding the IMR process, please
call Anthem Blue Cross’ Customer Service at
1-877-687-0549. If you have hearing or speech
loss, you may call our TTY line 1-888-757-6034.
Independent Medical Review
for Denials of Experimental/
Investigational Therapies
You may also be entitled to an Independent
Medical Review, through the DMHC, when we
deny coverage for treatment we have determined
to be experimental or investigational.
• Wewillnotifyyouinwritingofthe
opportunity to request an IMR of a decision
denying an experimental/investigational
therapy within five (5) business days of the
decision to deny coverage.
does not prohibit any legal rights or remedies
that may be available to you. If you need help
with a grievance involving an emergency, a
grievance that has not been satisfactorily resolved
by Anthem Blue Cross or a grievance that has
remained unresolved for more than thirty (30)
days, you may call the DMHC for assistance. You
may also be eligible for an Independent Medical
Review (IMR). If you are eligible for an IMR, the
IMR process will provide an impartial view of
coverage decisions made by a health plan related
to the medical necessity of a proposed service
or treatment, coverage decisions for treatments
that are experimental or investigational in nature
and payment disputes for emergency and urgent
medical services.
The DMHC has a toll-free telephone number,
1-888-HMO-2219, to receive complaints
regarding health plans. If you have hearing
or speech loss, you may use the DMHC’s
• YouarenotrequiredtoparticipateinAnthem
TDD line, 1-877-688-9891, to contact the
Blue Cross’ grievance process prior to seeking
DMHC. The DMHC’s Internet website
an IMR of our decision to deny coverage of
(http://www. hmohelp.ca.gov) has complaint
an experimental/investigational therapy.
forms, IMR application forms and instructions
• Ifaphysicianindicatesthattheproposed
online.
therapy would be significantly less effective
Anthem Blue Cross’ grievance process and the
if not promptly initiated, the IMR decision
DMHC’s complaint review process are in addition
shall be rendered within seven (7) days of the
to any other dispute resolution procedures that
completed request for an expedited review.
may be available to you, and your failure to use
these processes does not preclude your use of any
Review by the Department of
other remedy provided by law.
Managed Health Care
The California Department of Managed Health
Care is responsible for regulating health care
service plans. If you have a grievance against
Anthem Blue Cross, you should first telephone
Anthem Blue Cross at 1-877-687-0549 and use
Anthem Blue Cross’ grievance process before
contacting the DMHC. If you have hearing
1-888-757-6034. Using this grievance procedure
Binding Arbitration
This Binding Arbitration provision does not apply
to class actions.
ALL DISPUTES INCLUDING BUT NOT
LIMITED TO DISPUTES RELATING TO
THE DELIVERY OF SERVICE UNDER
THE PLAN OR ANY OTHER ISSUES
RELATED TO THE PLAN AND CLAIMS
46
Part 9
Grievance and Appeals Process OF MEDICAL MALPRACTICE MUST BE
RESOLVED BY BINDING ARBITRATION,
IF THE AMOUNT IN DISPUTE EXCEEDS
THE JURISDICTIONAL LIMIT OF SMALL
CLAIMS COURT. California Health and
Safety Code Section 1363.1 and Insurance Code
Section 10123.19 require specified disclosures
in this regard, including the following notice:
“It is understood that any dispute as to medical
malpractice, that is as to whether any medical
services rendered under this contract were
unnecessary or unauthorized or were improperly,
negligently or incompetently rendered, will
be determined by submission to arbitration as
provided by California law, and not by a lawsuit
or resort to court process except as California
law provides for judicial review of arbitration
proceedings. Both parties to this contract, by
entering into it, are giving up their constitutional
right to have any such dispute decided in a court
of law before a jury, and instead are accepting
the use of arbitration.” YOU AND ANTHEM
BLUE CROSS AGREE TO BE BOUND BY
THIS ARBITRATION PROVISION AND
ACKNOWLEDGE THAT THE RIGHT TO
A JURY TRIAL IS WAIVED FOR BOTH
DISPUTES RELATING TO THE DELIVERY
OF SERVICE UNDER THE PLAN OR ANY
OTHER ISSUES RELATED TO THE PLAN
AND MEDICAL MALPRACTICE CLAIMS.
The arbitration findings will be final and binding
except to the extent that state or federal law
provides for the judicial review of arbitration
proceedings.
The arbitration is initiated by the member
making a written demand on Anthem Blue Cross.
The arbitration will be conducted by Judicial
Arbitration and Mediation Services (JAMS),
according to its applicable rules and procedures. If
for any reason JAMS is unavailable to conduct the
arbitration, the arbitration will be conducted by
another neutral arbitration entity, by agreement
of the member and Anthem Blue Cross, or by
order of the court, if the member and Anthem
Blue Cross or Anthem Blue Cross Life and Health
Insurance Company cannot agree.
The costs of the arbitration will be allocated per
the JAMS Policy on Consumer Arbitrations. If
the arbitration is not conducted by JAMS, the
costs will be shared equally by the parties, except
in cases of extreme financial hardship, upon
application to the neutral arbitration entity to
whom the parties have agreed, in which cases,
Anthem Blue Cross will assume all or a portion of
the costs of the arbitration.
Please send all binding arbitration demands in
writing to:
ANTHEM BLUE CROSS
PO BOX 60007
The Federal Arbitration Act shall govern the
interpretation and enforcement of all proceedings
under this Binding Arbitration provision. To
the extent that the Federal Arbitration Act is
inapplicable, or is held not to require arbitration
of a particular claim, state law governing
agreements to arbitrate shall apply.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
47
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Part 10 If We No Longer Can Serve You •HarmorthreatentoharmAnthemBlueCross
or anyone who works for us; or if you harm
or threaten to harm any Anthem Blue Cross
participating provider or anyone who works
with them.
Sometimes Anthem Blue Cross, or your selected
provider, no longer can serve you.
•Youwon’tbecoveredbythisplanifyoumove
out of the service area for this plan.
•YoumayaskAnthemBlueCrossfor
continued care from a doctor whom we let go
from the Anthem Blue Cross network if you
are being treated for:
– An acute or serious chronic condition.
− A high-risk pregnancy.
− A second or third term pregnancy.
Such benefits will not apply to providers who have
been terminated due to medical disciplinary cause
or reason, fraud or other criminal activity.
If you are no longer in our plan, Anthem
Blue Cross will no longer pay for any health
services, medicines, or supplies.
What happens when I am no longer eligible for
the AIM program?
When you are no longer eligible for the AIM
program, call 1-800-777-6000 to find out about
other Anthem Blue Cross policies you may desire.
For more information, please call us at
1-877-687-0549. If you have hearing or
speech loss, you may call our TTY line
at 1-888-757-6034.
Sometimes we can’t keep you in
our plan
You no longer will be in our plan if the AIM
Program disenrolls you from the program. Please
see the handbook that the AIM program sent you.
It should tell you about this process under “What
You Need to Know After You are Enrolled.”
You also will no longer be in our plan if you are
disenrolled from Anthem Blue Cross. We can
ask the AIM program to do this. We may ask the
program to disenroll you from our plan if you:
•Engageinfraudintheuseoftheserviceswe
arrange or knowingly let someone else engage
in fraud. This includes letting someone else
use your Anthem Blue Cross card.
48
Part 11 Other Things You May Need to Know how much money they receive for the health care
of each member. These medical groups may receive
more money from Anthem Blue Cross because:
Advance Directive
You can file a form ahead of time to tell the doctor
or other health care provider what to do, or not
to do, if you are in danger of dying. It is called
an “advance directive.” You may change or cancel
your advance directive at any time.
•Theyprovidespecialtycare.Thisiscarefrom
a doctor who provides special services or
treatment, different from the primary care
doctor.
Benefits Are Not Transferable
You are the only person entitled to receive benefits
under this Evidence of Coverage. The right to
benefits cannot be transferred. Fraudulent use of
such benefits may result in your disenrollment
from Anthem Blue Cross and/or other appropriate
legal action.
Conformity with Law
•Theymanagepatienthealthcarewell.Thisis
when the doctor gives his or her patients good
medical care at a lower cost.
You are not responsible if Anthem Blue Cross does
not pay your doctor for covered benefits.
Hospitals and other health care facilities are paid
by Anthem Blue Cross in two different ways:
•Afixedamountofmoneyfortheservicethat
Anthem Blue Cross and the hospital or facility
agree upon in advance.
Any provision of this plan which, on the effective
date, is in conflict with any applicable statute,
regulation, or other law is hereby amended to
conform with the minimum requirements of such
law.
•Aloweramountofmoneyforservicethat
Anthem Blue Cross and the hospital or facility
agree upon in advance. You are not responsible
for the difference.
Expenses in Excess of Benefits
Your doctor may get financial incentives from
Anthem Blue Cross. You may ask Anthem
Blue Cross, your doctor, or your doctor’s medical
group for a written report of these incentives.
Neither Anthem Blue Cross nor the program is
liable for any expenses the member may incur in
excess of the benefits provided under this plan.
Form or Content of Evidence of
Coverage
Limitations of Other Coverage
No agent or employee of Anthem Blue Cross is
authorized to change the terms, conditions, or
benefits of this Evidence of Coverage.
How We Pay Our Providers
Anthem Blue Cross HMO for AIM pays the
doctors in our health plan in the following way.
Some of our doctors belong to large medical
groups. Anthem Blue Cross pays the medical group
a set amount of money for each member every
month. This is called a capitated payment. Anthem
Blue Cross and the medical group doctors agree on
49
This health plan coverage is not designed to
duplicate any benefits to which members are
entitled under government programs, including
CHAMPUS/TRICARE, Medi-Cal or Workers’
Compensation. By executing an enrollment
agreement, a member agrees to complete and
submit to Anthem Blue Cross such consents,
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
anthem.com/ca
Part 11 Other Things You May Need to Know releases, assignments and other documents
reasonably required by Anthem Blue Cross in order
to obtain or assure CHAMPUS/TRICARE or
Medi-Cal reimbursement or reimbursement under
the Workers’ Compensation law.
• Every27minutessomeonegetsanorganfrom
a donor.
Member-Provider Relationship
• Morethan95,000peopleintheUnitedStates
are waiting for organs right now.
• Organscanbedonatedandtransportedto
where they are needed to be transplanted,
sometimes over 100 miles away.
The medical group and its PCPs will provide all
covered medically necessary professional services in a
manner compatible with a member’s wishes, as long
as this can be done consistently with the doctor’s
judgment regarding the requirements of proper
medical practice. Certain members may refuse to
accept procedures or treatment recommended by
the PCP. However, if a member refuses to accept
a recommended treatment or procedure and the
doctor believes that no professionally acceptable
alternative exists, you will be advised. No doctor has
to render or authorize treatment deemed medically
unacceptable by that doctor.
Public Participation
We have a Consumer Relations/Public Policy
Committee to help our Board of Directors. This
group is made up of members of our health plan,
providers in our network, and a member of our
board. This group makes sure the comfort and
dignity of our members is considered. It makes sure
our services are easy to access for our members. The
committee will provide input on the Cultural and
Linguistics Needs Assessment. The committee may
look at the way we use our funding. They may also
review complaints we receive from our members.
The Consumer Relations/Public Policy Committee
reports to our Board of Directors.
Notifying You of Changes
Throughout the year we may send you updates
about changes. This can include updates for the
Provider Directory, Handbook, and Evidence
of Coverage. We will keep you informed and
are available to answer any questions you may
have. Call us at1-877-687-0549 if you have any
questions about changes in the plan. If you have
hearing or speech loss, you may call our TTY line at
1-888-757-6034.
If you would like to be considered for membership
on the Consumer Relations/Public Policy
Committee, please call our Customer Service at
1-877- 687-0549. If you have hearing or speech loss,
you may call our TTY line at 1-888-757-6034.
Receipt of Information
To administer claims on your behalf, we are
entitled to receive service or treatment information
about you from any provider. This right to
receive information is subject to all applicable
confidentiality requirements.
Organ Donation
You can help save lives and give people a chance
to live a normal life by becoming an organ donor.
If you are between 15 and 18 years old, you can
become a donor just like an adult, with the written
consent of your parent or guardian. You can change
your mind about becoming an organ donor at any
time. Here are a few facts about organ donation:
•Bysubmittinganapplicationforcoverage,you
have authorized every provider furnishing care to
disclose all facts pertaining to your care, treatment
and physical condition, upon our request.
•Youagreetoassistinobtainingthisinformation
if needed.
• Every3hourssomeoneintheUnitedStates
dies because of the lack of organ donors.
50
Part 11 Other Things You May Need to Know •Youcanhaveaccesstoyourmedicalrecordsas
allowed by law.
Third Party Recovery Process and
Member Responsibilities
The member agrees that, if benefits of this agreement
are provided to treat an injury or illness caused by the
wrongful act or omission of another person or third
party, provided that the member is made whole for
all other damages resulting from the wrongful act
or omission before Anthem Blue Cross is entitled to
reimbursement, member shall:
•ReimburseAnthemBlueCrossforthe
reasonable cost of services paid by Anthem
Blue Cross to the extent permitted by
California Civil Code section 3040
immediately upon collection of damages by
her, whether by action or law, settlement or
otherwise; and
•Sendtheitemizedbillwithacompleted
member claim form to:
ANTHEM BLUE CROSS
PO BOX 60007
Right to Recovery
When any amount paid by Anthem Blue Cross
exceeds the amount due under this Evidence of
Coverage, Anthem Blue Cross has the right to
recover the excess amount from the member unless
prohibited by law.
Terms of Coverage
Your benefits depend on what is covered on the
date you get the service. The services covered
by Blue Cross can be changed without your
agreement.
We will let you know of any changes by mail.
• FullycooperatewithAnthemBlueCross’
effectuation of its lien rights for the reasonable
value of services provided by Anthem Blue Cross
to the extent permitted under California Civil
Code section 3040. Anthem Blue Cross’ lien
may be filed with the person whose act caused
the injuries, her agent or the court.
Reimbursement Provisions – If You
Receive a Bill
If you do not tell your doctor or other health care
provider that you have coverage with AIM, you
may have to pay the bills. If you get a bill while you
have coverage, take care of it right away. If you don’t
take care of it, the doctor may send the bill to a
collection agency. If you get a bill follow these steps
•Callusat1-877-687-0549torequestamember
claim form. If you have hearing or speech loss,
you may call our TTY line at 1-888-757-6034.
•Obtainanitemizedbillfromyourdoctoror
other health care provider.
• CoverageintheAIMprogramforthe
subscriber is for the duration of the pregnancy
and includes services following the pregnancy
for 60 days.
• Ifweneedtotellyouaboutanychangesinthe
plan, we will do so at least 30 days prior to the
change. We will contact you at the address we
have in our records. If your address changes,
please contact the AIM program at
1-800-433-2611.
• Theserviceswegivearesubjecttothelaw
governing the plan (Division 1 of Title 28 of
the California Code of Regulations).
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
51
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Part 11 Other Things You May Need to Know We are also subject to the Knox-Keene Health Care
Service Plan Act of 1975 (California Health and
Safety Code, Chapter 2.2 of Division 2), including
amendments and applicable regulations.
Nonduplication of Benefits with
Workers’ Compensation
If, pursuant to any Workers’ Compensation or
Employer’s Liability Law or other legislation
of similar purpose or import, a third party is
responsible for all or part of the cost of medical
services provided by Anthem Blue Cross, we
will provide the benefits of this agreement at the
time of need. The member will agree to provide
Anthem Blue Cross with a lien on such Workers’
Compensation medical benefits to the extent of
the reasonable value of the services provided by
Anthem Blue Cross. The lien may be filed with the
responsible third party, her agent or the court.
For purposes of this subsection, reasonable value
will be determined to be the usual, customary or
reasonable charge for services in the geographic area
where the services are rendered.
By accepting coverage under this Agreement,
members agree to cooperate in protecting the
interest of Anthem Blue Cross under this provision
and to execute and to deliver to Anthem Blue Cross
or its nominee any and all assignments or other
documents which may be necessary or proper to
fully and completely effectuate and protect the
rights of Anthem Blue Cross or its nominee.
52
Part 12 Your Health Care Rights and
Responsibilities
•Makerecommendationsaboutourrightsand
responsibilities policy.
What are your health care rights?
As an Anthem Blue Cross member, you have the
right to:
What are your responsibilities as a
health care consumer?
•Beinformedofyourrightsand
responsibilities.
As an Anthem Blue Cross member, your
responsibilities are to:
•ReceiveinformationaboutAnthemBlueCross
services, doctors and specialists.
•GiveAnthemBlueCross,yourdoctors,and
other health care providers the information
needed to treat you, to the best of your ability.
•Receiveinformationaboutallyourother
health care providers.
•Understandyourconditionandhelpyour
doctor set treatment goals you both agree on,
to the best of your ability.
•Talkhonestlywithyourdoctorsaboutallthe
appropriate treatments for your condition,
no matter what they cost or whether your
benefits cover them.
•Followtheplansyouhaveagreedonwith
your doctors and your other health care
providers.
•Useinterpreterswhoarenotyourfamily
members or friends (the interpreter will be
provided at no charge to you).
•Followtheguidelinesforhealthylivingyour
doctor and your other health care providers
suggest.
•Betreatedwithrespectandwithregardfor
your dignity in all situations.
•Usetheemergencyroomonlyincasesofan
emergency or as directed by your provider.
•HaveyourprivacyprotectedbyAnthem
Blue Cross, your doctors and all your other
health care providers.
•Knowthatinformationaboutyouiskept
confidential and used only to treat you.
• Youhavetherighttobeinchargeofyour
health care.
•Beactivelyinvolvedinmakingdecisions
about your health care.
• MakeanAdvanceDirective.
• Youhavetherighttosuggestchangesinyour
health plan.
•ComplainaboutAnthemBlueCrossorthe
health care you receive.
•Fileacomplaintorgrievanceifyourcultural
and linguistic needs are not met.
TTY: 1-888-757-6034
•AppealadecisionfromAnthemBlueCross
about the health care you receive.
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
53
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Part 13 Definitions Here are some of the terms used in this booklet:
Access for Infants and Mothers (AIM) means
the state program administered by MRMIB to
provide maternity care coverage to women who
meet the eligibility and income requirements and
pay the member’s contribution.
Accidental Injury means physical harm or
disability, which is the result of a specific,
unexpected incident caused by an outside
force. The physical harm or disability must
have occurred at an identifiable time and place.
Accidental injury does not include illness or
infection, except infection of a cut or wound.
Active Labor means labor where there is inadequate
time to safely transfer the member to another
hospital prior to delivery or when transferring the
member may pose a threat to the health and safety
of the member or the unborn child.
Acute Condition means a medical condition
that involves a sudden onset of symptoms due
to an illness, injury or other medical problem
that requires prompt medical attention and has a
limited duration.
Benefits (Covered Services) are those services,
supplies, and drugs that a member is entitled to
receive pursuant to the terms of this agreement.
A service is not a benefit, even if described as
a covered service or benefit in this booklet,
if it is not medically necessary or if it is not
provided by an Anthem Blue Cross provider with
authorization as required.
Benefit Year means the twelve (12) month period
commencing October 1 of each year at 12:01 a.m.
Anthem Blue Cross: A health care service plan,
regulated by the California Department of
Managed Health Care, and contracting with the
program to administer this plan. .
Brand Name Prescription Drug means a
prescription drug that has been patented and is
produced by only one manufacturer.
Capitated means that we pay your medical group
to take care of all your health care. Check your ID
card; if it says CAP, that means you belong to a
capitated group.
Complaint is also called a grievance or appeal.
Examples of a complaint can be when:
Ambulatory Surgical Center means a
freestanding outpatient surgical facility that must
be licensed as an outpatient clinic according
to state and local laws and must meet all
requirements of an outpatient clinic providing
surgical services. It also must meet accreditation
standards of the Joint Commission on
Accreditation of Health Care Organizations or the
Accreditation Association of Ambulatory Care.
Authorization means that certain services must
be OK’d by Anthem Blue Cross and your doctor
before you receive them for the services to be
covered. Prior authorization means the services
must be authorized before you receive them.
• Youcan’tgetaservice,treatmentormedicine
you need.
• Yourplandeniesaserviceandsaysitisnot
• Youhavetowaittoolongforanappointment.
• Youreceivedpoorcareorweretreatedrudely.
• Yourplandoesnotpayyoubackforemergency
or urgent care that you had to pay for.
• Yougetabillthatyoubelieveyoushouldnot
have to pay.
Continuity of care means your right to continue
seeing your doctor in certain cases, even if your
doctor leaves your health plan or medical group.
54
Part 13 Definitions Contracting Hospital means a hospital that has
an Anthem Blue Cross HMO plan agreement
in effect at the time services are rendered. Please
contact Anthem Blue Cross to determine if a
hospital is contracting.
Customary and Reasonable means a charge, as
determined annually by Anthem Blue Cross, that
falls within the common range of fees billed by a
majority of physicians for a procedure in a given
geographic region, or a charge that is justified
based on the complexity or severity of treatment
for a specific case.
Coordination of Benefits (COB) means that
if you are covered by another health plan, that
plan will pay first and the AIM health plan will
pay second for any services you receive under the
AIM program. The total of the two payments can
not be more than the total amount allowed by
the AIM health plan. For more details on COB,
please refer to your Anthem Blue Cross AIM
Evidence of Coverage booklet.
Disenroll means to stop using the health plan,
because you lose eligibility, quit the health plan, or
because you don’t pay your monthly premium.
Durable Medical Equipment (DME) means
medical equipment, like hospital beds and
wheelchairs, which can be used over and over again.
Effective Date means the date your coverage
under this Evidence of Coverage begins. It appears
on your Anthem Blue Cross ID card.
Cosmetic Surgery means surgical procedures to
alter or reshape normal structures of the body in
order to improve appearance. Note: Cosmetic
surgery does not become reconstructive surgery
because of psychological or psychiatric reasons.
Emergency is a medical or psychiatric condition
with such severe symptoms (including active labor
or severe pain) that a prudent layperson who has
an average knowledge of health and medicine,
could reasonably believe that the lack of immediate
medical attention could lead to any of these:
Covered Expense means the expense incurred
by a member for covered services, but not more
than the customary and reasonable charge or
the maximum amounts stated in the applicable
Benefit sections of this Evidence of Coverage.
•Placeyourhealth(orthehealthofyour
unborn baby) in jeopardy.
Covered Services medically necessary services
or supplies, listed in the benefit sections of this
Evidence of Coverage that members are entitled to
receive under this plan.
•Causeimpairmenttoabodilyfunction.
•Causedysfunctionofabodyorganorpart.
Outside of your service area, emergencies include
urgently needed services to prevent serious
deterioration of your health resulting from
area.
Custodial Care means care provided primarily
to meet the personal needs of the member. This
includes help with walking, bathing or dressing.
It also includes preparing food or special diets,
feeding, administration of medicine (usually
self-administered), or any other care that does not
require continuing services of medical personnel.
Custodial care is not a covered benefit under this
Evidence of Coverage.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
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Part 13 Definitions Evidence of Coverage and Disclosure Form
(EOC) means this booklet that is the combined
Evidence of Coverage and Disclosure Form that
describes the services your health plan covers and
does not cover.
The provider must:
Exclusion means any medical, surgical, hospital,
service or other treatment for which the program
offers no coverage.
Some of the health care providers include:
•HavealicensetopracticeinCalifornia.
•Giveyouaservicethatispaidforunderthis
plan.
•Audiologist:testsyourhearing
•CertifiedNurseMidwife:aclinicianwho
can take care of you during pregnancy and
childbirth
Experimental or Investigational Service means
those drugs, equipment, procedures or services
that are in a testing phase undergoing laboratory
or animal studies prior to human testing or for
which laboratory and animal studies have been
completed and for which human studies are in
progress but:
•FamilyPractitioner:adoctorwhotreatsgeneral
medical conditions for people of all ages
•GeneralPractitioner:adoctorwhotreats
general medical conditions
•HomeHealthAgencyandVisitingNurse
Associations: give you skilled nursing care and
other services in your home
• Testingisincomplete.
• Theefficacyandsafetyofsuchservicesin
human subjects is not yet established.
•LicensedVocationalNurse:performsmore
complex nursing functions along with your
doctor and is licensed with the state
• Theserviceisnotinwideusage.
Generic Prescription Drug means a
pharmaceutical equivalent of one or more
brand name drugs. It must be approved by the
Food and Drug Administration as meeting the
same standards of safety, purity, strength and
effectiveness as the brand name drug.
•Marriage,FamilyandChildCounselor:helps
you with family problems
•MedicalAssistant:anonlicensedpersonwho
helps your doctors to give you medical services
(may also be called a certified medical assistant)
Grievance means a written or oral expression
of dissatisfaction regarding the plan and/or
doctor, including quality of care concerns, and
shall include a complaint, dispute, request for
reconsideration, or appeal made by a member or
the member’s representative. Where the plan is
unable to distinguish between a grievance and an
inquiry, it shall be considered a grievance.
•NurseAnesthetist:anursewhogivesyou
anesthesia
•NursePractitionerorPhysician’sAssistant:
clinicians who can take care of you, find out
what’s wrong and treat you
•Obstetrician-Gynecologist:adoctorwhotakes
care of women’s health, including prenatal
care and delivery of babies (an obstetriciangynecologist can also provide primary care)
Health Care Provider means many kinds of
doctors and specialists and other health care
providers who are covered under this plan (for
example, surgeons, doctors who treat cancer or
doctors who treat special parts of your body).
•OccupationalTherapist:helpsyouregain
skills and activities of daily living after an
illness or injury
56
Part 13 Definitions •Pediatrician:adoctorwhoonlytreatschildren Independent Medical Review (IMR) means a
from birth to adolescence
review of your health plan’s denial of your request
for a certain service or treatment. (The review is
•PhysicalTherapist:helpsyoubuildyour
provided by the Department of Managed Health
physical strength after an illness or injury
Care and conducted by independent medical
•PodiatristorChiropodist:afootdoctor
experts, and your health plan must pay for the
•Psychologist:adoctorwhotreatsmental
service if an IMR decides you need the service).
problems
Infant means the subscriber’s child born while the
•RegisteredNurse:hasmoreextensivetraining
than an LVN (the RN is licensed with the
state to perform certain complex duties along
with your doctor)
subscriber is enrolled in this program.
•RespiratoryTherapist:helpsyouwithyour
breathing
Maintenance Prescription Drugs mean
prescription drugs that are taken for an extended
period of time as treatment for a medical condition.
Inpatient care means when you have to stay in
the hospital or other facility to get the medical
care you need.
•SpeechPathologist:helpsyouwithyourspeech
Health Insurance Portability and
Accountability Act (HIPAA) means a law that
protects your rights to get health insurance and to
keep your medical records private.
Managed Risk Medical Insurance Board
(MRMIB): The State agency that administers the
Access for Infants and Mothers (AIM) program.
Medically Necessary means those procedures,
supplies, equipment or services determined to fit
all the following criteria:
Healthy Families Program (HFP) means the
state program administered by MRMIB to
provide medical, dental and vision coverage to
children who meet the eligibility and income
requirements and member’s parent or guardian
pay a monthly contribution.
•Appropriateforthesymptoms,diagnosisor
treatment of a medical condition
•Providedforthediagnosisordirectcareand
treatment of the medical condition
Hospital means a health care facility licensed by
the state of California, and accredited by the Joint
Commission on Accreditation of Health Care
Organizations, as either: (a) an acute care hospital;
(b) a psychiatric hospital; or (c) a hospital
operated primarily for the treatment of alcoholism
and/or substance abuse. A facility that is primarily
a rest home, nursing home or home for the aged,
or a distinct part of a skilled nursing facility
portion of a hospital is not included.
•Withinthestandardsofgoodmedicalpractice
within the organized medical community
•Notprimarilyfortheconvenienceofthe
patient’s physician or other provider
•Themostappropriateprocedure,supply,
equipment or service which can be safely
provided
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
57
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Part 13 Definitions Member means a person who is enrolled in
Anthem Blue Cross to receive her health care. In
this booklet, a member is also referred to as “you.”
determined to be unnecessary, according to these
utilization review procedures. A list of participating
hospitals is available upon request.
Mental Health Care Services means
psychoanalysis, psychotherapy, counseling,
medical management, or other services commonly
provided by a psychiatrist, psychologist, licensed
clinical social worker, or marriage and family
therapist, for diagnosis and treatment of mental
or emotional disorders or the mental or emotional
problems associated with an illness, injury or any
other condition.
Participating Medical Group means a group of
providers contracted with Anthem Blue Cross to
provide services to HMO members.
Network Pharmacy means a pharmacy that has
a network pharmacy agreement in effect with
Anthem Blue Cross pharmacy plan at the time
services are rendered.
Non-network Pharmacy means a pharmacy that
does not have a network pharmacy agreement in
effect with Anthem Blue Cross pharmacy plan
at the time services are rendered. You will be
responsible for payment in full for any prescriptions
obtained at a non-network pharmacy.
Participating Physician means a physician
who has an HMO participating agreement
with Anthem Blue Cross at the time services
are rendered. A list of participating physicians is
available upon request.
Participating Provider means a physician,
hospital, skilled nursing facility or other licensed
health care professional, licensed facility or
licensed home health agency, who or which, at
the time service is rendered to the member, has
a contract in effect with Anthem Blue Cross to
provide services to its members.
Physician means a doctor of medicine (MD) or
a doctor of osteopathy (DO) who is licensed to
practice medicine or osteopathy where the care is
provided.
Orthotic Device means a support or brace
designed for the support of a weak or ineffective
joint or muscle, or to improve the function of
movable body parts.
Plan means the Anthem Blue Cross HMO
plan described in this Evidence of Coverage and
administered by Anthem Blue Cross for the state
of California.
Outpatient care means when you do not have
to stay in the hospital or other facility to get the
medical care you need.
Preferred Drug List (PDL) means a list of
brand-name and generic prescription drugs and
supplies preferred by Anthem Blue Cross for use
as the first line of drug therapy. Just because a
prescription drug or supply is on the PDL does
not guarantee that your doctor will order it for a
certain condition.
Paid Surrogate Mother means a subscriber
who, in advance of her pregnancy, enters into
an agreement to become pregnant and deliver a
child for another person as the intended parent, in
exchange for monetary compensation other than
actual medical or living expenses.
Participating Hospital means a hospital that
has an HMO participating agreement in effect
with Anthem Blue Cross at the time services are
rendered. Participating hospitals agree to participate
in procedures established to review the utilization of
hospital services. We do not cover hospital services
Primary Care Provider (PCP) means the
doctor you have chosen to give you most of your
health care. He or she helps you get the care
you need. He or she must OK any care ahead
of time, unless it’s an emergency. The PCP is a
general practitioner, internist, pediatrician, family
practitioner or an obstetrician/gynecologist.
58
Part 13 Definitions Prior Authorization means that certain services
must be OK’d by Anthem Blue Cross and your
doctor before you receive them for the service to
be covered.
Serious Chronic Condition means a medical
condition due to a disease, illness or other medical
problem or medical disorder that is serious in
nature and persists without full cure or worsens
over an extended period of time or requires
ongoing treatment to maintain remission or
prevent deterioration.
Program means the Access for Infants and
Mothers (AIM) program
Prosthetic Device means an artificial device used
to replace a body part.
Serious Emotional Disturbance (SED) means a
diagnosed mental condition in a child that is not
a “substance abuse disorder” or “developmental
disorder.” A child with SED also behaves in a
way that is not appropriate for the child’s age.
A county mental health department decides
if a child has SED based on California Law
(Welfare and Institutions Code Section 5600.3(a)
(2)). In making that decision, the county will
consider whether a child has certain problems.
These could include trouble taking care of him/
herself, problems at school or problems with
family relationships. The child also might have
other problems such as being at risk of suicide
or violence. Or, the child might meet the state’s
Special Education requirements. The county also
may look at whether the child is at risk of being
removed from the home and at how long the
condition is expected to last.
Psychiatric Emergency Medical Condition
means a mental disorder with acute symptoms of
sufficient severity to render either an immediate
danger to yourself or others, or you are
immediately unable to provide for or use, food,
shelter, or clothing due to the mental disorder.
Psychiatric Mental Health Nurse means
a registered nurse with a master’s degree in
psychiatric mental health nursing who meets the
qualifications for registration, and is registered
as a psychiatric mental health nurse with the
California Board of Registered Nurses.
Reconstructive Surgery means surgery that is
done when there is something wrong with a part
of your body, caused by birth defects, disease or
injury. It is done for medical reasons to make that
part work better or to make it look fairly normal.
Referral means a recommendation by a physician
or insurer, that an individual receive care from a
different doctor or facility. Also, authorization for
a member of a managed care plan to receive care
from a specialist or hospital. The member’s primary
care provider generally must provide the referral.
Rules of the Program means the statutes, laws,
and regulations of the board that govern the
program and determines the qualifications for and
rights and duties of members. The statutes are in
Part 6.3 of Division 2 (beginning with Section
12695) of the California Insurance Code, and
the regulations of the Board are in Chapter 5.6 of
Title 10 of the California Administrative Code.
TTY: 1-888-757-6034
24/7 NurseLine: 1-800-224-0336
24/7 NurseLine TTY: 1-800-368-4424
59
anthem.com/ca
Part 13 Definitions Severe Mental Illnesses (SMI) refers to a
diagnosed mental condition. SMI means:
Triage or Screening Waiting Time means the
time waiting to speak by telephone with a doctor
or nurse who is trained to screen AIM members
who may need care.
•Schizophrenia
•Schizoaffectivedisorder
Urgent Care means services needed to prevent
serious deterioration of a member’s health resulting
from unforeseen illness or injury for which
treatment cannot be delayed.
• Panicdisorder
• Anorexianervosa
• Bulimianervosa
Service Area means Anthem Blue Cross’ service
area. This service area is the state of California.
Your service area is the geographical area within
thirty (30) minutes travel time or fifteen (15) miles
of where you live or work.
Skilled Nursing Facility means a facility licensed
by the California State Department of Health
Services as a “Skilled Nursing Facility” to provide
inpatient skilled nursing care and related services
to patients who require medical, nursing or
rehabilitative services but do not require the level
of care provided in a hospital.
Special Care Units means special areas of a
hospital that have highly skilled personnel and
special equipment for acute conditions that require
constant treatment and observation.
Terminal illness means an incurable or irreversible
condition that has a high probability of causing
death within one (1) year or less.
Triage or Screening means the evaluation of an
AIM member by a doctor or nurse who is trained
to screen for the purpose of determining the
urgency of the member’s need for care.
60
Map of the Plan’s Service Area
Anthem Blue Cross Access for Infants
and Mothers (AIM) Program
Anthem HMO
Anthem EPO
Not Covered by Anthem
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered
trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan
members. WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license by Express Scripts, Inc.
©2010
0912 CA0014970 12/12