Important Notice from Anthem Blue Cross - Select HMO About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Anthem Blue Cross - Select HMO prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage.  This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage.  If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.
Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY: 800-325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:
• Visit www.medicare.gov for personalized help.
• Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.

This brochure describes the benefits of the Anthem Blue Cross - Select HMO Plan under Anthem Blue Cross contract (CS 2936) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 800-235-8631 or through our website: www.anthem.com/ca. The address for Anthem Blue Cross' administrative offices is:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA. 90060-0007

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page 82. Rates are shown at the end of this brochure.

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples: 

• Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Anthem Blue Cross Select HMO.
• We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
• Our brochure and other FEHB Plans’ brochures have the same format and similar descriptions to help you compare plans.

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

• Do not give your plan identification (ID) number over the phone or to people you do not know, except for your health care providers, authorized health benefits plan, or OPM representative.
• Let only the appropriate medical professionals review your medical record or recommend services.
• Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
• Carefully review explanations of benefits (EOBs) statements that you receive from us.
• Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
• Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
• If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
  • Call the provider and ask for an explanation. There may be an error.
  • If the provider does not resolve the matter, call us at 800-235-8631 and explain the situation. 
  • If we do not resolve the issue:
    

    CALL - THE HEALTH CARE FRAUD HOTLINE

    877-499-7295

    Or go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

    The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

    You can also write to:

    United States Office of Personnel Management
    Office of the Inspector General Fraud Hotline
    1900 E Street NW Room 6400
    Washington, DC 20415-1100

• Do not maintain as a family member on your policy:
  • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
  • Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26)
    A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.
• If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
• Fraud or intentional misrepresentation of material fact is prohibited under the Plan.  You can be prosecuted for fraud and your agency may take action against you.  Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
• If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.

The Anthem Blue Cross Select HMO complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights compliant with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO, 1900 E Street NW, Suite 3400 S, Washington, DC 20415-3610.

Get help in your language

Curious to know what all this says? We would be too. Here’s the English version:
You have the right to get this information and help in your language for free. Call the Member Services number on your ID card for help. (TTY/TDD: 711)

For the translation of this statement in: Spanish, Chinese, Vietnamese, Korean, Tagalog, Russian, Arabic, Armenian, Farsi, French, Japanese, Haitian, Italian, Polish, Punjabi, and Navajo please visit our website at www.anthem.com.

Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card.

It’s important we treat you fairly
That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 800-368-1019, TDD: 800-537-7697 or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare.  Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

• Ask questions and make sure you understand the answers.
• Choose a doctor with whom you feel comfortable talking.
• Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

• Bring the actual medications or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
• Tell your doctor and pharmacist about any drug, food and other allergies you have, such as to latex.
• Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
• Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than you expected.
• Read the label and patient package insert when you get your medications, including all warnings and instructions. 
• Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
• Contact your doctor or pharmacist if you have any questions.
• Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

• Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
• Don’t assume the results are fine if you do not get them when expected.  Contact your healthcare provider and ask for your results. 
• Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

• Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.
• Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

• Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
• Ask your doctor, “Who will manage my care when I am in the hospital?”
• Ask your surgeon:
  • "Exactly what will you be doing?"
  • "About how long will it take?"
  • "What will happen after surgery?"
  • "How can I expect to feel during recovery?"
• Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

• www.jointcommission.org/speakup.aspx.  The Joint Commission’s Speak Up™ patient safety program.
• www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.
• www.ahrq.gov/patients-consumers/.  The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.  
• www.bemedwise.org.  The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
• http://www.leapfroggroup.org/.  The Leapfrog Group is active in promoting safe practices in hospital care.
• http://www.ahqa.org/.  The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility.  These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. Should an event occur and you were required to make payments to the provider you will be reimbursed for your out-of-pocket costs.  The list of Never Events or Hospital Acquired Conditions is as follows:

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Unintended retention of a foreign object in a patient after surgery or other procedure
• Air embolism
• Blood Incompatibility
• Surgical site infection following bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery)
• Surgical site infection, mediastinitis, following coronary artery bypass graft
• Surgical site infection following certain orthopedic procedures (spine, neck, shoulder, elbow)
• Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures (total knee replacement, hip replacement)
• Catheter associated urinary tract infection
• Manifestations of poor glycemic control (diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity)
• Vascular catheter associated infection
• Falls and trauma (fracture, dislocation, intracranial injury, crushing injury, burn, electric shock)
• Pressure ulcers, stages III and IV

Coverage Information

When you lose benefits

General features of our HMO

This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Anthem Blue Cross Select HMO holds the following accreditation: Accredited status with the National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation(s), please visit the following website: National Committee for Quality Assurance (www.ncqa.org).

We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the Plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).  Your medical group is paid a set amount for each member per month. Your medical group may also get added money for some types of special care or for overall efficiency, and for managing services and referrals. Hospitals and other health care facilities are paid a set amount for the kind of service they provide to you or an amount based on a negotiated discount from their standard rates. If you want more information, please call us at 800-235-8631, or you may call your medical group.

You do not have to pay any Anthem Blue Cross-Select HMO provider for what we owe them, even if we don’t pay them. But you may have to pay a non-Plan provider any amounts not paid to them by us.

Preventive care services

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

Your Rights and Responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers.  OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you.  Some of the required information is listed below.

• Anthem Blue Cross has been serving the health insurance needs of California residents since 1937.
• Profit status - Blue Cross of California is a for-profit California corporation

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website, Anthem Blue Cross Select HMO at www.anthem.com/ca.   You can also contact us to request that we mail a copy to you.

If you want information about us, call 800-235-8631, or write to Anthem Blue Cross, P.O. Box 60007 Los Angeles, CA. 90060-0007.  You may also visit our website at www.anthem.com/ca.

By law, you have the right to access your protected health information (PHI).  For more information regarding access to PHI, visit our website Anthem Blue Cross Select HMO at www.anthem.com/ca to obtain our Notice of Privacy Practices.  You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:

Southern California Counties

Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Ventura

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency or urgent care services. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan.  If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas.  If you or a family member move, you do not have to wait until Open Season to change plans.  Contact your employing or retirement office.

Do not rely only on these change description; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Changes to this Plan:

• Your share of the non-Postal premium will decrease for Self Only, decrease for Self Plus One, and decrease for Self and Family enrollment.   See page 86.
• Previously LiveHealth Online visits were covered with a $30 copayment.  LiveHealth Online visits will now be covered with a $10 copayment.
• Previously there was no benefit for Retail Health Clinic visits. Now Retail Health Clinic visits will be covered with a $30 copay.
• Previously there was no benefit for fertility preservation services to prevent iatrogenic infertility when medically necessary. Now fertility preservation services to prevent iatrogenic infertility when medically necessary are covered under the Infertility benefits.
• Previously bereavement services, including assessing the needs of the bereaved family and developing a care plan to meet those needs, both before and after death. Bereavement services are available to covered members of the immediate family (spouse, children, step-children, parents, brothers and sisters) for up to one year after the employee’s or covered family member’s death. Now bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the member’s death. Bereavement services are available to the patient and those individuals who are closely linked to the patient, including the immediate family, the primary or designated care giver and individuals with significant personal ties, for one year after the member’s death.
• Previously preventive care medications included Vitamin D and Iron supplements. Vitamin D and Iron supplements will no longer be covered.
• Second opinion visits were covered for surgical procedures.  Now second opinion visits will be covered for all conditions.
• Aids for Non-verbal Communication. Devices and computers to assist in communication and speech except for speech aid devices and tracheoesophageal voice devices approved by Anthem are not covered.
• Autopsies and post-mortem testing are not covered.
• Services, supplies or room and board for teaching, vocational, or self-training purposes. This includes, but is not limited to boarding schools and/or the room and board and educational components of a residential program where the primary focus of the program is educational in nature rather than treatment based are not covered.
• Services rendered by hospital resident doctors or interns that are billed separately. This includes separately billed charges for services rendered by employees of hospitals, labs or other institutions, and charges included in other duplicate billings are not covered.
• Disposable supplies for use in the home such as bandages, gauze, tape, antiseptics, dressings, ace-type bandages, and any other supplies, dressings, appliances or devices that are not specifically listed as covered are not covered.
• Wilderness or other outdoor camps and/or programs. This exclusion does not apply to medically necessary services to severe mental disorders or serious emotional disturbances of a child, as required by state or federal law.
• Any investigational drugs or devices, non-health services required for you to receive the treatment, the costs of managing the research, or costs that would not be a covered service under this plan for non-Investigative treatments, unless specifically stated are not covered.
• Currently the plan offers a Medicare Advantage plan called Anthem Blue Cross Senior Secure. We removed the plan name from Section 9.
• Dental devices and oral appliances for snoring.
• Private duty nursing services given in a hospital or skilled nursing facility are not covered.

See page 15 for how our benefits changed this year.  Page 82 is a benefits summary of our high option.  Make sure that you review the benefits that are available under the option in which you are enrolled.

The benefit package is described in Section 5. Make sure that you carefully review the benefits that are available.  

Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 800-235-8631 or on our website at www.anthem.com/ca.

When you seek care from within our network, we offer the following unique features:

• No deductibles
• No office visit copay for covered preventive care services
• $30 non-preventive primary care office visit copay  
• $30 office visit copay for family planning visits
• $10 telehealth visit with LiveHealth Online
• $150 emergency room copay
• $250 per day copay up to a maximum of 4 days per covered inpatient hospital admission
• $250 outpatient facility copay for surgery

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.
• The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.  Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
• Be sure to read Section 4, Your costs for covered services for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.
• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS.  Please refer to Section 3 to be sure which services require precertification. 

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Plan doctors must provide or arrange your care and you must be hospitalized in a Plan facility.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.
• The amounts listed below are for the charges billed by the facility (i.e. hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e. physicians, etc.) are in Section 5(a) or (b).

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What is urgent care?

We provide coverage for medically necessary care by non-Plan providers to prevent serious deterioration of your health resulting from an unforeseen illness or injury when you are more than 15 miles (or 30 minutes) from your medical group (or your medical group's enrollment area hospital if you are enrolled in an independent practice association), and seeking health services cannot wait until you return.

If you need urgent care you should seek medical attention immediately. If you are admitted to a hospital for urgently needed care, you should contact your primary care physician or Medical Group within 48 hours, unless extraordinary circumstances prevent such notification. Follow-up care will be covered when the care required continues to meet our definition of "Urgent Care". Urgent care is defined as services received for a sudden, serious, or unexpected illness, injury or condition, which is not an emergency, but which requires immediate care for the relief of pain or diagnosis and treatment of such condition.

What to do in case of emergency.

If you need emergency services, get the medical care you need right away. In some areas, there is a 9-1-1 emergency response system that you may call for emergency services (this system is to be used only when there is an emergency that requires an emergency response).

Once you are stabilized, your primary care physician must approve any care you need after that.

• Ask the hospital or emergency room doctor to call your primary care physician.
• Your primary care physician will approve any other medically necessary care or will take over your care

If You Are In-Area

You are in-area if you are 15-miles or 30-minutes or less from your medical group (or 15-miles or 30-minutes or less from your medical group’s hospital, if your medical group is an independent practice association).

If you need emergency services, get the medical care you need right away.  If you want, you may also call your primary care physician and follow his or her instructions.

Your primary care physician or medical group may:

• ask you to come into their office;
• give you the name of a hospital or emergency room and tell you to go there;
• order an ambulance for you;
• give you the name of another doctor or medical group and tell you to go there;  or
• tell you to call the 9-1-1 emergency response system.

If You're Out of Area

You can still get emergency services if you are more than 15-miles or 30-minutes away from your primary care physician or medical group.

If you need emergency services, get the medical care you need right away (follow the instructions above for What to do in case of emergency).  In some areas, there is a 9-1-1 emergency response system that you may call for emergency services (this system is to be used only when there is an emergency that requires an emergency response). You must call us within 48 hours if you are admitted to a hospital.

Remember:

• We will not cover services that do not fit what we mean by emergency services.
• Your primary care physician must approve care you get once you are stabilized, unless Anthem Blue Cross Select HMO approves it.
• Once your medical group or Anthem Blue Cross-Select HMO give an approval for emergency services, they cannot withdraw it.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.
• You can get care for outpatient professional treatment of mental health and substance use conditions by a Plan provider without getting prior approval from your medical group. In order for care to be covered, you must go to a Plan provider. You can get a directory of Plan providers from us by calling 800-235-8631.
• We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
• OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

Important things to keep in mind about these benefits:

• We cover prescribed drugs and medications, as described in the chart beginning on page 57.
• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
• Federal law prevents the pharmacy from accepting unused medications.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage.

There are important features you should be aware of. These include the following.

Who can write your prescription?

A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication. Certain over-the-counter items for tobacco cessation, nicotine replacement, FDA-approved contraceptives for women, vitamins, supplements, and health aids, may be covered when obtained with a doctor’s prescription. This rule does not apply to pneumonia or seasonal flu vaccinations provided at a member drug store.

Where you can obtain them.

You may fill the prescription at any licensed retail participating or non-participating pharmacy, by the mail service program or from our Specialty Pharmacy.  When using a plan pharmacy you have two levels to choose from. Level 1 pharmacies will have lower copayments and Level 2 pharmacies will have higher copayments. Call us at 800-235-8631 or visit our website at https://www.anthem.com/ca/federal-employees/health-plans/ for information on how to obtain a listing of the Level 1 and Level 2 pharmacies.  It will cost you more if you go to a non-participating pharmacy.

Using Participating Pharmacies.

To get medication your physician has prescribed, go to a participating pharmacy. For help finding a participating pharmacy, call us at 800-235-8631 or the Pharmacy Member Services number on the back of your identification card. Show your Member ID card to the participating pharmacy and pay your copayment for the covered medication. You must also pay for any medication or supplies that are not covered under the Plan. 

If you believe you should get some plan benefits for the medication that you have paid the cost for, have the pharmacist fill out a claim form and sign it.  Send the claim form to us (within 90 days) to:

Claims Department
P.O. Box 52065
Phoenix, AZ 85072-2065

If the member drugstore doesn’t have claims forms, or if you have questions, call 800-235-8631 or the Pharmacy Member Services number on the back of your identification card.

Using Non-Participating Pharmacies.

It will cost you more if you go to a non-participating pharmacy. Take a claim form with you to the non-member drugstore.  If you need a claim form or if you have questions, call us at 800-235-8631 or the Pharmacy Member Services number on the back of your identification card. Have the pharmacist fill out the form and sign it. Then send the claim form (within 90 days) to:

Claims Department
P.O. Box 52065
Phoenix, AZ 85072-2065

Once the claim is received we will deduct any non-covered costs, including any cost above the non-member drugstore fee schedule (except when drugs are related to urgent care or emergency services) and your copayment.  The rest of the cost is covered.

If you are out of state, and you need medication, call us at 800-235-8631 or the Pharmacy Member Services phone number on the back of your identification card to find out where there is a member drugstore. If there is no member drugstore, pay for the drug and send the pharmacy benefit manager a claim form.

Getting your medication through the mail.

To order prescriptions through the mail, your prescription from your health care provider should reflect the drug name, how much and how often to take it, how to use it, the provider’s name, address and telephone number as well as your name and address. You must complete the order form. The first time you use the mail service program, you must also send a completed Patient Profile questionnaire. Be sure to send your copay along with the prescription, the order form, and the Patient Profile. You can pay by check, money order, or credit card. Send your order to:

Pharmacy Home Delivery 
P.O. Box 94467
Palatine, IL 60094-4467

There may be some medications you cannot order through this program, such as drugs to treat sexual dysfunction.  Call 800-235-8631 or the Pharmacy Member Services phone number on the back of your identification card to find out if you can order your medication through the Mail Service.

Compound Medication  Compound medications do not include duplicates of existing products and supplies that are mass-produced by a manufacturer for consumers, nor products lacking an NDC number.  Compound medications must be dispensed by a member drugstore. Call 800-235-8631 or the Pharmacy Member Services number on the back of your identification card to find out where to take your prescription for an approved compound medication to be filled. (You can also find a member drugstore at https://www.anthem.com/ca/federal-employees/health-plans/) Some compound medications must be approved before you can get them (see "Drugs that need to be approved" below). You will have to pay the full cost of the compound medications you get from a drugstore that is not a member drugstore.

Specialty drugs are high-cost, injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of their effect on the patient by a medical professional. These drugs often require special handling, such as temperature controlled packaging and overnight delivery, and are often unavailable at retail drugstores.  You may obtain a list of medications from our website https://www.anthem.com/ca/federal-employees/health-plans/.

Getting your medication through the Specialty Pharmacy.

You can only order specialty drugs through the Specialty Pharmacy Program unless you are given an exception from the Specialty Pharmacy Program. The Specialty Pharmacy Program only fills specialty drug prescriptions and will deliver your medication to you by mail or common carrier. The prescription for the specialty drug must state the drug name, dosage, directions for use, quantity, the doctor’s name and phone number, the patient's name and address, and be signed by a doctor. You or your doctor may order your specialty drug by calling the Pharmacy Member Services number on the back of your identification card. When you call the Specialty Pharmacy Program, a dedicated care coordinator will guide you through the process up to and including actual delivery of your specialty drug to you. If you order your specialty drug by telephone, you will need to pay by credit card or debit card. You may also submit your specialty drug prescription with the appropriate payment for the amount of the purchase (you can pay by check, money order, credit card or debit card), and a properly completed order form to the Specialty Pharmacy Program at the address shown below. The first time you get a prescription for a specialty drug you must also include a completed Intake Referral Form by calling the toll-free number below. You need only enclose the prescription or refill notice, and the appropriate payment for any subsequent specialty drug prescriptions, or call the toll-free number. Copays can be paid by check, money order, credit card or debit card.

You or your doctor may obtain a list of specialty drugs available through the Specialty Pharmacy Program or order forms by contacting Member Services at 800-235-8631 or online at www.anthem.com/ca.

Claims Department
P.O. Box 52065
Phoenix, AZ 85072-2065

If you don’t get your specialty drug through the Specialty Pharmacy Program, you might not receive benefits under this plan for them.

Exceptions to Specialty Pharmacy Program. This requirement does not apply to:

A. The first two month’s supply of a specialty pharmacy drug which is available through a member drugstore;
B. Drugs, which due to medical necessity, must be obtained immediately; or
C. A member for whom, according to the coordination of benefit rules, this plan is not the primary plan.

How to obtain an exception to the Specialty Pharmacy Program.

If you believe you should not be required to get your medication through the Specialty Pharmacy Program, for any of the reasons listed above, except for C, you must complete an Exception to Specialty Drug Program form and send it to the pharmacy benefits manager by fax or mail. To request an Exception to Specialty Drug Program form, call the pharmacy benefits manager at the Pharmacy Member Services phone number on the back of your identification card. You can also get the form on-line at www.anthem.com/ca. If the pharmacy benefits manager has given you an exception, it will be in writing and will be good for 6 months from the time it is given. After 6 months, if you believe you should still not be required to get your medication through the Specialty Pharmacy Program, you must again request an exception. If the pharmacy benefits manager denies your request for an exception, it will be in writing and will explain why it was not approved.

Urgent or emergency need of a specialty drug subject to the Specialty Pharmacy Program.

If you are out of a specialty drug which must be obtained through the Specialty Pharmacy Program, the pharmacy benefits manager may authorize an override of the Specialty Pharmacy Program requirement for 72 hours, or until the next business day following a holiday or weekend.  This will allow you to get an emergency supply of medication if your doctor decides it is appropriate and medically necessary. You may have to pay the applicable copay for the 72 hour supply of your drug.  If you order your specialty pharmacy drug through the Specialty Pharmacy Program and it does not arrive, and your doctor decides it is medically necessary for you to have the drug immediately, we will authorize an override of the Specialty Pharmacy Program requirement for a 30-day supply or less to allow you to get an emergency supply of medication from a member drug store near you. A dedicated care coordinator from the Specialty Pharmacy Program will coordinate the exception and you will not be required to make an additional copay.

We use a formulary.

The fact that a drug is on this list doesn’t guarantee that your doctor will prescribe you that drug. This list, which includes both generic drugs and brand name drugs, is updated quarterly so that the list includes drugs that are safe and effective in the treatment of disease. The Essential prescription drug list is a list of pharmaceutical products, developed in consultation with physicians and pharmacists, approved for their quality and cost effectiveness. The covered prescription drug list is subject to periodic review and amendment. Except as otherwise stated, certain drugs may not be covered if they are not on the Essential prescription drug list.  Some drugs need to be approved - the doctor or drugstore will know which drugs they are. If you have a question regarding whether a particular drug is on our formulary drug list or requires prior authorization please call us at the telephone number on the back of your identification card.  Information about the drugs on our formulary drug list is also available on our internet website www.anthem.com/ca.

New drugs and changes in the prescription drugs covered by the plan.

The National Pharmacy and Therapeutics Committee decides which outpatient prescription drugs are to be included on the prescription drug formulary covered by the plan. The National Pharmacy and Therapeutics Committee is comprised of independent doctors and pharmacists that meet quarterly and decide on changes needed to the prescription drug formulary list based on recommendations and a review of relevant information, including current medical literature. If your current medication changes to a higher Tier level as a result of this review, you will not be responsible for the higher Tier copayment. If the change results in a lower Tier level, you will be responsible for the lower Tier copayment. For example if your current medication is a Tier 2 drug and the National Pharmacy and Therapeutics Committee feels it should be a Tier 3, you will continue to pay the Tier 2 copayment. However, should the committee decide to put your medication in the Tier 1 category, you will begin paying the lower Tier 1 copayment.

These are the dispensing limitations for drugs from a retail pharmacy, Specialty Pharmacy Program, or the mail service program.

You can get a 30-day supply if you get it at the drugstore or through the Specialty Pharmacy Program. You can get a 60-day supply of drugs at the drugstore for treating attention deficit disorder if they are FDA approved for the treatment of attention deficit disorder, are federally classified as Schedule II drugs, and require a triplicate prescription form. If the doctor prescribes a 60-day supply for drugs classified as Schedule II for the treatment of attention deficit disorders, you have to pay double the amount of copay for retail drugstores. You can get a 90-day supply if you get it from our mail service program. If you get the drugs through our mail service program, the copay will be the same as for any other drug.

A generic equivalent will be dispensed if it is available.

When your doctor prescribes a brand-name drug that has a generic option, your pharmacy will automatically fill the prescription using the generic drug. You will pay less for the generic drug.  When the brand-name drug has a generic option and you and your doctor still choose the brand-name drug, or your doctor writes “dispense as written,” you will be responsible for paying the generic drug copayment plus the difference between the cost of the generic and the brand-name drug. 

If your doctor prescribes a brand-name drug and it has no generic option, or if a doctor shows that the brand-name drug is medically necessary for you, you’ll only have to pay the brand-name copayment with no extra cost.

Why use generic drugs?

Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs. You can save money by using generic drugs. However, you and your physician have the option to request a name-brand if a generic option is available. Using the most cost-effective medication saves money.

Special Programs

From time to time, we may initiate various programs to encourage you to utilize more cost-effective or clinically-effective drugs including, but, not limited to, generic drugs, mail service drugs, over-the-counter drugs or preferred drug products. Such programs may involve reducing or waiving co-payments for those generic drugs, over-the counter drugs, or the preferred drug products for a limited time. If we initiate such a program, and we determine that you are taking a drug for a medical condition affected by the program, you will be notified in writing of the program and how to participate in it.

Half-tab Program

The Half-Tablet Program allows you to pay a reduced co-payment on selected “once daily dosage” medications. The Half-Tablet Program allows you to obtain a 30-day supply (15 tablets) of a higher strength version of your medication when the prescription is written by the doctor to take “½ tablet daily” of those medications on a list approved by us. The National Pharmacy and Therapeutics Committee will determine additions and deletions to the approved list.  The Half-Tablet Program is strictly voluntary and your decision to participate should follow consultation with and the concurrence of your doctor.  To obtain a list of the products available on this program call the Pharmacy Member Services number on the back of your identification card or go to our internet website www.anthem.com/ca.

Prescription drug tiers are used to classify drugs for the purpose of setting their co-payment. Anthem will decide which drugs should be in each tier based on clinical decisions made by the National Pharmacy and Therapeutics Committee. Anthem retains the right at its discretion to determine coverage for dosage formulation in terms of covered dosage administration methods (for example, by mouth, injection, topical or inhaled) and may cover one form of administration and may exclude or place other forms of administration in another tier (if it is medically necessary for you to get a drug in an administrative form that is excluded you will need to get written prior authorization (see “Drugs that need to be approved above) to get that administrative form of the drug).  This is an explanation of what drugs each tier includes:

• Tier 1 Drugs are those that have the lowest co-payment.  This tier contains low cost preferred drugs that may be generic, single source brand name drugs, biosimilars, interchangeable biologic products or multi-source brand name drugs.

• Tier 2 Drugs are those that have higher copayments than Tier 1 Drugs, but, lower than Tier 3 Drugs. This tier may contain preferred drugs that may be generic, single source brand name drugs, biosimilars, interchangeable biologic products or multi-source brand name drugs.

• Tier 3 Drugs are those that have the higher copayments than Tier 2 Drugs, but, lower than Tier 4 Drugs. This tier may contain higher cost preferred drugs and non-preferred drugs that may be generic, single source brand name drugs, biosimilars, interchangeable biologic products or multi-source brand name drugs.

• Tier 4 Drugs are those that have the higher copayments than Tier 3 Drugs. This tier may contain higher cost preferred drugs and non-preferred drugs that may be generic, single source brand name drugs, biosimilars, interchangeable biologic products or multi-source brand name drugs.

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with Medicare and other coverage .
• Your medical group must provide or arrange for your care.
• We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is described below. See Hospital benefits (Section 5(c)).
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating benefits with Medicare and other coverage .

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information contact the Plan at, 800-235-8631 or visit their website at www.anthem.com/ca.

Discount programs

You can receive negotiated savings on selected health and wellness services and programs simply by being an eligible Anthem Blue Cross Select HMO member. To obtain information about these programs please call us at 800-235-8631 or visit our website at www.anthem.com/ca. Services available through the discount program includes but are not limited to:

• Puritan’s Pride – discounts on various vitamins, minerals and supplements
• LivingFree – discount on smoking cessation classes
• LivingEasy – discounts on stress management programs
• LivingLean – discounts on weight-loss programs
• LifeMart – deals on beauty/skin care, diet plans, fitness clubs, spas and more
• Safebeginnings – discounts on baby-proofing products
• HelpCare Plus – Senior Care Services with access to a pharmacy discount card
• EyeMed – discounts on glasses and accessories
• HearPO – discounts on hearing aids
• TruVision – preferred pricing on LASIK eye surgery
• GlobalFit– discounts on gym memberships, fitness equipment, coaching and more 

Anthem Protect short-term disability insurance

Income protection exclusively for federal employees

Plan highlights:

• Flexible design; customize insurance plan and benefits specific to your budget and life circumstances.
• Guaranteed acceptance; federal employees are eligible regardless of health history
• Quick-and-easy enrollment process
• Lump-sum cash benefits provided if you suffer a covered disability

Who is eligible?

An applicant is eligible for Anthem Protect short-term disability insurance if they are a federal civilian employee working in the United States for a minimum of 20 hours per week. Applicant can enroll in insurance during the annual open enrollment period or within 60 days from date they become eligible.

Make sure help is available when you need it!

Questions? Please contact the number listed on your ID card or visit anthem.com/federal to sign up today.

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury or condition.

We do not cover the following:

• Care by non-Plan providers except for authorized referrals or emergencies (see Section 5(d) for Emergency services).
• Services, drugs, or supplies you receive while you are not enrolled in this Plan.
• Services or supplies that are not medically necessary.
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
• Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
• Services, drugs, or supplies you receive without charge while in active military service.
• Care you got from a health care provider without the approval of your primary care doctor or a doctor specializing in OB-GYN in your medical group, except for emergency services or urgent care.
• Services not listed as being covered by this Plan.
• Any services actually given to you by a local, state or federal government agency, or by a public school system or school district, except when this Plan’s benefits, must be provided by law.  We will not cover payment for these services if you are not required to pay for them or they are given to you for free.
• Treatment or services rendered by non-licensed health care providers and treatment or services for which the provider of services is not required to be licensed.  This includes treatment or services from a non-licensed provider under the supervision of a licensed doctor, except as specifically provided or arranged by us. This exclusion does not apply to the medically necessary treatment of pervasive developmental disorder or autism, to the extent stated in the section “Benefits for Pervasive Developmental Disorder or Autism”.
• Services you are not required to pay for or are given to you at no charge, except services you got at a charitable research hospital (not with the government).  This hospital must:
  • Be known throughout the world as devoted to medical research.
  • Have at least 10% of its yearly budget spent on research not directly related to patient care.
  • Have 1/3 of its income from donations or grants (not gifts or payments for patient care).
  • Accept patients who are not able to pay.
  • Serve patients with conditions directly related to the hospital’s research (at least 2/3 of their patients).
• Care for health problems that are work-related if such health problems are or can be covered by workers’ compensation, an employer’s liability law, or a similar law.  We will provide care for a work-related health problem, but, we have the right to be paid back for that care.
• Weight loss programs, whether or not they are pursued under medical or doctor supervision, unless specifically listed as covered in this Plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or for treatment of anorexia nervosa or bulimia nervosa.
• Services or supplies provided pursuant to a private contract between the member and a provider, for which reimbursement under the Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.
• This plan does not cover educational or academic services as follows:
• Educational or academic counseling, remediation, or other services that are designed to increase academic knowledge or skills.
• Educational or academic counseling, remediation, or other services that are designed to increase socialization, adaptive, or communication skills.
• Academic or educational testing.
• Teaching skills for employment or vocational purposes.
• Teaching art, dance, horseback riding, music, play, swimming, or any similar activities
• Teaching manners and etiquette or any other social skills.
• Teaching and support services to develop planning and organizational skills such as daily activity planning and project or task planning
• Services, supplies or room and board for teaching, vocational, or self-training purposes. This includes, but is not limited to boarding schools and/or the room and board and educational components of a residential program where the primary focus of the program is educational in nature rather than treatment based

This exclusion does not apply to the medically necessary treatment of pervasive developmental disorder or autism, to the extent stated in the section “Benefits for Pervasive Developmental Disorder or Autism”.

• Services or supplies furnished by yourself, immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption.
• Autopsies and post-mortem testing are not covered.

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).  See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures.  When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims.  Just present your identification card and you pay your copayment, coinsurance or deductible, if applicable.

You will only need to file a claim when you receive emergency services from non-plan providers.  Sometimes these providers bill us directly.  Check with the provider.

If you need to file the claim, here is the process:

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes.  For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-services claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing to Anthem Blue Cross-Select HMO, P.O. Box 4310, Woodland Hills, CA  93167 or calling 800-235-8631.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision.  The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-235-8631.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM's FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

• Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure.  You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.anthem.com/federal/ca.
• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
• We only cover services provided or arranged by Plan physicians, unless you receive an authorized referral or the services are for emergency or urgent care.

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

• Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
• Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees.

USPS Human Resources Shared Service Center: 1-877-477-3273, option 5, Federal Relay Service 1-800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.