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HMO Plan - California

Contact

Anthem Blue Cross Select HMO Network
P.O. Box 60007
Los Angeles, CA 90060
Group #: 281366

Member Services - (800) 227-3771
Behavioral Health - (800) 399-2421
Pharmacist Services- (800) 824-0898

www.anthem.com\ca


Information

A Health Maintenance Organization (HMO) medical plan is available to employees, Research Associates, External Graduate Students and their dependents. TSRI Graduate Students are not eligible for this plan. The network of providers is Anthem Blue Cross Select HMO Network. To search for a primary care physician click, on Anthem Network of Providers or call Anthem at (800) 227-3771. Please note that Scripps Clinic is not available in the Anthem Blue Cross Select HMO Network.

An HMO plan requires the employee to designate a primary care physician (PCP) who will coordinate all care received including providing referrals to specialists. Prescriptions and Mental Health services are also provided through the HMO plan. Vision services are provided separately through MES Vision.

The chart below outlines the main provisions of the HMO medical plan.

Medical Coverage
Outpatient Services
Annual Deductible: waived for preventive care and office visits $100 per person
$200 per family
Out-of-Pocket Max $2500 per person
$5000 per family
PCP Office Visits/Specialist Office Visit $30 co-pay/$40 co-pay
Outpatient Surgery 90% after deductible
Diagnostic Lab/Diagnostic X-ray 100% covered/$40 co-pay X-Ray/$150 co-pay Complex X-Ray
Inpatient Services
Urgent Care $50 per visit
Emergency Room $100 co-pay after deductible
Inpatient Hospital Charges 90% after deductible
Other Services
Well Baby Care 100% covered
Adult Periodic Exams 100% covered
Well Woman Exams 100% covered
Immunizations 100% covered
Chiropractic Care $15 co-pay; 20 visits/year
Acupuncture None

Prescriptions Retail (30 day supply) Mail Order (90 day supply)
Rx Deductible $100/person, $200/family (applies to brand formulary and non-formulary drugs only)
Generic $10 $20
Brand Name $35 $70
Non-Formulary $60 $120

Mental Health Coverage
Inpatient Care 90% after deductible
Outpatient Care $40 co-pay

Alcohol & Substance Abuse Coverage
Inpatient Hospitalization/ Detoxification 90% after deductible
Outpatient Services $40 co-pay