solution ppo plans - ehealthinsurance...• you save money because we’ve negotiated lower rates...
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Solution PPO Plans
Summary of Features
Small Group EmployeeElect
Solution 5000 PPO
MCASB2931C (7/09)
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Solution 5000 PPO: Combines a modest premium PPO plan with a high deductible, providing predictable copays for office visits and prescription drugs along with coverage for preventive care and physical exams
It’s just the right amount of coverage for you.
• Yougetupto$5,000,000incoveredbenefitsoveryourlifetime.
• Youchoosefromover53,000doctorsandspecialists,andfromover400hospitals.
• Yousavemoneybecausewe’venegotiatedlowerrateswithourin-networkdoctors.
• YougetemergencycarecoveredwhiletravelingacrosstheU.S.andthroughouttheworld,24/7.
Great Ways to Save!
AnthemBlueCrossisworkinghardtohelpyousavemoneyonhealthcarecosts.Oneoftheeasiestandmostconvenientwaystosaveisbyorderingmaintenancemedicationsthroughourmail-orderpharmacy.Yourmedicationsaredeliveredrighttoyourdoor,andwithourlowermail-orderpharmacybenefits,youcansaveasmuchas$80ormoreperyearonprescriptioncosts!Andnow,yourplanoffersgenericmedicationsata$10copay,savingyouevenmore.
You can save over 66 percent on pharmacy costs using mail order!
Ourmail-orderservicepharmacyisaprovenmoneysaver.Geta90-daymail-ordersupplyforthesamecostasa30-dayretailsupplyforgenerics!Gowithbrandformularyorbrandnonformularymedicationsandgeta90-daysupplyforthesamecostasa60-dayretailsupply.Mailorderslashesprescriptioncostsbygivingyougreatersuppliesofmaintenancemedicationsforaslittleasone-thirdthecost.
Anthem 360° Health®: Optimize Your Health
360°Healthoffersyouvaluabletools,resourcesandsupporttohelpyoutolivehealthier,startingtoday.Andit’sallavailablethroughonecentralizedresource.Whetheryouarehealthyandwanttostaythatwayoryouneedhelpmanagingachroniccondition,360°Healthisheretohelpyoureachyourpersonalhealthgoals.
Access Tools and Resources
Atanthem.com/ca,360°Healthbringstogether:
• Onlineresources(likehelpfuldecision-makingtoolsandvaluablehealthinformation).
• Interactivehealthprograms.
• Personalguidance.
• Discountsonhealth-relatedproducts.
•MyHealth@Anthem,yourpersonalonlineresourceformemberhealthandwellnessinformation.Ourtrustedsitehasinteractivetoolsthathelpyoucheckyourhealthstatusandlearnwhatyoucandotoimproveit.
Get Guidance
Sometimesyouneedexpertinformationandsupportfromatrustedsource.Weprovideprogramstoaddressyourconcernsandgiveyoutheassistanceyouneedinreachingyourhealthgoals.
Solid protection,practical solution
* Member pays full cost of drug at negotiated rates until brand-name deductible is met. Costs may vary for brand name drugs if generic equivalent is available.
Manage a Condition
OurConditionCareprogramscanhelpyoubettermanagechronicconditionsincludingasthma,diabetes,heartfailure,coronaryarterydiseaseandchronicobstructivepulmonarydisease.Visitanthem.com/catodaytolearnmoreabouthow360°Healthcanhelpyoulivebettertodayandinthefuture.
We’re dedicated to improving your health.
WithAnthem,you’llhavepeaceofmindknowingthatyou’recoveredbyoneofthemosttrustednamesinhealthcarecoverage,andthatyou’regettingmorevalueinsomanyways.Westillhavethesamecommitmenttoyouthatwe’vehadtoallCaliforniansoverthelast70years—todeliverhigh-quality,affordablehealthcoverageandhelpyoubeashealthyasyoucanbe.AsthehealthcareplanmoreCaliforniansdependon,welookforwardtoservingyourhealthcareneeds.
Haveaquestion?JustcallSmallGroupCustomerServiceat800-627-8797andwe’llbehappytohelp.
Comprehensive coverage you can trust. Modest premiums with predictable office visit copays. Preventive care and physical exam coverage and valuable hospital coverage. That’s what makes our Solution 5000 PPO Plan a practical, cost-effective solution.
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You’re free to go to health care providers outside
of the Anthem Blue Cross network, but you’ll save
a substantial amount by choosing from our 53,000
doctors and 400 hospitals. Staying in the Anthem
Blue Cross network will help you get maximum
value from your health care benefits — and from
your health care dollar.
Powerful savings from Anthem
With Anthem health coverage, you save in three significant ways:
1.Ourin-networkdoctorsandhospitalschargeyoulower,AnthemBlueCross-negotiatedfees.
2.TheBlueCard®programgivesyouaccesstoin-networkprovidersatdiscountedratesallacrossthecountry.
3.Youpayonlyaportionofthefeesforyoureligiblecoveredexpenses(seeexamplebelow)andwepaytherest,afteryourdeductible.
Thisisanexampleonly.Yoursavingsmayvarybasedonyourplanandservicesreceived.
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Small Group Solution 5000 PPO PlanAll amounts listed are the member’s responsibility to pay after deductible(s), unless otherwise noted. In-network negotiated fees can result in 30 to 40% savings compared to providers’ usual fees.
CORE FEATURES IN NETWORK Receive Negotiated Savings
OUT OF NETWORK Pay Higher Costs
Annual Deductible $5,000 per member for all medical services except office visits, annual physical exam and prescription drugs; two-member maximum, in network and out of network combined. Annual deductible applies toward annual in-network out-of-pocket maximum
Maximum Lifetime Covered ChargesPaid by Anthem Blue Cross In network and out of network combined
$5,000,000
Annual Out-of-Pocket Maximum1 $7,500 per member, two-member maximum Once Anthem Blue Cross payments reach $15,000 per member, member pays nothing for covered expenses for the remainder of the year except charges over the allowed amounts
Office Visits Not subject to annual deductible
$40 copay for unlimited visits 50% of negotiated fee plus 100% of excess charges
Other Professional ServicesIncludes maternity, diagnostic lab and X-ray
40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible
Hospital Inpatient Facility Services Pre-service Review required
40% of negotiated fee after annual deductible All charges in excess of $650 per day after annual deductible
Hospital Inpatient Professional Services Includes lab, physician, anesthesia
40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible
Outpatient Facility Services Pre-service Review required for certain surgical services and diagnostic procedures
40% of negotiated fee after annual deductible All charges in excess of $380 per day after annual deductible
Ambulatory Surgical Centers Pre-service Review required
40% of negotiated fee after annual deductible All charges in excess of $380 per day after annual deductible
Prescription Drugs3
Amounts shown are for a 30-day retail supply; mail-order service available
Annual $250 brand-name prescription drug deductible per member applies to brand-name drugs in network and out of network combined
Generic: $10 copay
Brand2:$250 brand-name prescription drug deductible applies$35 copay for Formulary$50 copay for Non-FormularySelf-injectable (except insulin): 30% of negotiated fee up to $100 per fill (subject to brand-name prescription drug deductible, if applicable)
50% of drug limited fee schedule plus 100% of excess charges if filled within California. $250 brand-name deductible applies.
Annual Preventive Care OptionsPhysical Exam (Ages 7 - Adult)Maximum Anthem Blue Cross payment of $500 for members covered more than 6 months or $250 if covered 6 months or less; not subject to annual deductible; in network and out of network combined. HealthyCheckSM Screenings do not apply.
$40 copay per office visit plus 40% of negotiated fee for all other covered services
50% of negotiated fee plus 100% of excess charges
1 Services that do not apply to the annual out-of-pocket maximum include but are not limited to: deductible and copay paid under the pharmacy benefit; copay paid for acupuncture/acupressure; copay for mental or nervous disorders and substance abuse (except for treatment of severe mental illness and serious emotional disturbances of a child); copay for not obtaining pre-service review; $500 copay for infertility services; non-covered services.
2 Copays listed apply when generic equivalent is not available. If a member selects a brand-name drug when a generic-equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for a generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug. The additional amount paid does not apply to the member’s brand-name deductible.3 Infertility Drugs: Infertility drug lifetime maximum Anthem Blue Cross payment is $1,500 in network and out of network combined. Classified specialty drugs must be obtained through the Specialty Pharmacy Program and are subject to the terms of the program.
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1 Age and frequency limitations apply.2 Does not apply to coverage of severe mental illness and serious emotional disturbances of a child, except pre-service review. 3 Classified specialty drugs must be obtained through the mail-order Specialty Pharmacy Program and are subject to the terms of the program. Limited to 30-day supply.
This is an overview of coverage. A comprehensive description of coverage, benefits and limitations is contained in the Certificate. Review the Exclusions and Limitations prior to applying for coverage.
ADDITIONAL FEATURES IN NETWORK Receive Negotiated Savings
OUT OF NETWORK Pay Higher Costs
Well Baby Immunizations and Adult Screening Tests1 Well-Baby Immunizations (Children through age 6) Includes regular check-ups and immunizations
Adult Preventive Services (Ages 7 - Adult) Includes annual Pap, breast exam and mammogram for women, and Prostate Specific Antigen study for men, and colorectal cancer screenings.
$40 copay for office visit (not subject to deductible) plus 40% of negotiated fee for all other covered services after annual deductible
50% of negotiated fee plus 100% of excess charges after annual deductible
Emergency Care$100 Emergency Room copay for each visit - waived if admitted
40% of negotiated fee after annual deductible 40% of customary and reasonable charges plus 100% of excess after annual deductible
Ambulance 40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible
Skilled Nursing Facility100 days per year, in network and out of network combined Pre-service Review required
40% of negotiated fee after annual deductible All charges in excess of $150 per day after annual deductible
Home Health Care100 four-hour visits per year, in network and out of network combined Pre-service Review required
40% of negotiated fee after annual deductible All charges in excess of $75 per visit after annual deductible
Physical/Occupational Therapy, Chiropractic Care24 visits per year, in network and out of network combined
40% of negotiated fee after annual deductible All charges in excess of $25 per visit after annual deductible
Acupuncture/Acupressure24 visits per year, in network and out of network combined
All of the negotiated fee in excess of $30 per visit after annual deductible All charges in excess of $30 per visit after annual deductible
Mental Health/Inpatient2
Includes chemical dependency; 30 days per year, in network and out of network combined
Pre-service Review required
All of the negotiated fee in excess of $175 per day after annual deductible All charges in excess of $175 per day after annual deductible
Mental Health/Outpatient Professional Services2
Includes chemical dependency. One visit per day, 20 visits per year, in network and out of network combinedPre-service Review required after the 12th outpatient professional visit
All of the negotiated fee in excess of $25 per visit after annual deductible All charges in excess of $25 per visit after annual deductible
Infusion Therapy3
Includes chemotherapyPre-service Review required
40% of negotiated fee after annual deductible All charges in excess of $50 per day for all infusion therapy expenses except drugs; all charges in excess of the average wholesale price for all infusion therapy drugs; all charges in excess of the combined maximum Anthem Blue Cross payment of $500 per day; after annual deductible
Infertility Services3
Maximum lifetime Anthem Blue Cross payment $2,000, in network and out of network combined
$500 copay plus 40% of the balance of negotiated fee after annual deductible $500 copay plus 50% of the balance of negotiated fee plus 100% of excess charges after annual deductible
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Exclusions and Limitations
Followingisanabbreviatedlistofexclusionsandlimitations;pleaseseetheCertificateforcomprehensivedetails.
•AnyamountsinexcessofmaximumsstatedintheCertificate
•Servicesorsuppliesthatarenotmedicallynecessary
•Servicesreceivedbeforeyoureffectivedate
•Servicesreceivedafteryourcoverageends
•Anyconditionsforwhichbenefitscanberecoveredunderanyworkers’compensationlaworsimilarlaw
•Servicesyoureceiveforwhichyouarenotlegallyobligatedtopay
•Servicesforwhichnochargeismadetoyouintheabsenceofinsurancecoverage
•ServicesnotlistedascoveredintheCertificate
•Servicesfromrelatives
•VisioncareexceptasspecificallystatedintheCertificate
•Eyesurgeryperformedsolelyforthepurposeofcorrectingrefractivedefects
•Hearingaids.RoutinehearingtestsexceptasspecificallystatedintheCertificate
•Sexchanges
•DentalandorthodonticservicesexceptasspecificallystatedintheCertificate
•Cosmeticsurgery
•RoutinephysicalexaminationsexceptasspecificallystatedintheCertificate
•Treatmentofmentalornervousdisordersandsubstanceabuse(includingnicotineuse)orpsychologicaltesting,exceptasspecificallystatedintheCertificate
•Custodialcare
•Experimentalorinvestigationalservices
•Servicesprovidedbyalocal,stateorfederalgovernmentagency,unlessyouhavetopayforthem
•Diagnosticadmissions
•Telephoneorfacsimilemachineconsultations
•Personalcomfortitems
•Nutritionalcounseling
•Healthclubmemberships
•Commercialweightlossprograms,unlessapprovedbyus
•Medicalsuppliesandequipment/durablemedicalequipment,exceptasspecificallystatedintheCertificate
•Specialtydrugs,exceptasspecificallystatedintheCertificate
•AnyservicestotheextentyouareentitledtoreceiveMedicarebenefitsforthoseserviceswithoutpaymentofadditionalpremiumforMedicarecoverage
•Foodordietarysupplements,exceptasspecificallystatedintheCertificateorasrequiredbylaw
•Genetictestingfornon-medicalreasonsorwhenthereisnomedicalindicationornofamilyhistoryofgeneticabnormality
•Outdoortreatmentprograms
•Replacementofprostheticsanddurablemedicalequipmentwhenlostorstolen
•AnyservicesorsuppliesprovidedtoanypersonnotcoveredundertheAgreementinconnectionwithasurrogatepregnancy
•ImmunizationssolelyfortraveloutsidetheUnitedStates
•Servicesorsuppliesrelatedtoapre-existingcondition
•EducationalservicesexceptasspecificallyprovidedorarrangedbyAnthemBlueCross
•Infertilityservices(includingsterilizationreversal)exceptasspecificallystatedintheCertificate
•Careortreatmentprovidedinanon-contractinghospital
•PrivatedutynursingexceptasspecificallystatedintheCertificate
•Servicesprimarilyforweightreductionexceptmedicallynecessarytreatmentofmorbidobesity
•Outpatientdrugs,medicationsorothersubstancesdispensedoradministeredinanyoutpatientsetting
•Contraceptivedevicesunlessyourphysiciandeterminesthatoralcontraceptivedrugsarenotmedicallyappropriatelaw
General Provisions
Member Privacy: OurcompleteNotice of Privacy Practicesprovidesacomprehensiveoverviewofthepoliciesandpracticesweenforcetopreserveourmembers’privacyrightsandcontroluseoftheirhealthcareinformation,including:therighttoauthorizereleaseofinformation;therighttolimitaccesstomedicalinformation;protectionoforal,writtenandelectronicinformation;useofdata;andinformationsharedwithemployers.Thisnoticecanbedownloadedfromourwebsiteatanthem.com/caorobtained
bycallingSmallGroupCustomerServiceat800-627-8797.
Utilization Review: TheAnthemBlueCrossUtilizationReviewProgramhelpsmembersreceivecoverageforappropriatetreatmentintheappropriatesetting.Fourreviewprocessesareincluded:1)Pre-serviceReviewassessesmedicalnecessitybeforeservicesareprovided;2)AdmissionReviewdeterminesatthetimeofadmissionifthestayorsurgeryisMedicallyNecessaryintheeventPre-serviceReviewisnotconducted;3)ContinuedStayReviewdeterminesifacontinuedstayisMedicallyNecessary;4)RetrospectiveReviewdeterminesifthestayorsurgerywasMedicallyNecessaryaftercarehasbeenprovidedifnoneofthefirstthreereviewswereperformed.UtilizationReviewisnotthepracticeofmedicineortheprovisionofmedicalcaretoyou.Onlyyourdoctorcanprovideyouwithmedicaladviceandmedicalcare.
Grievances: Allcomplaintsanddisputesrelatingtoamember’scoveragemustberesolvedinaccordancewithAnthemBlueCrossLifeandHealthInsuranceCompany’sgrievanceprocedure.Youcanreportyourgrievancebyphoneorinwriting;seeyourAnthemBlueCrossLifeandHealthInsuranceCompanyIDcardfortheappropriatecontactinformation.AllgrievancesreceivedbyAnthemBlueCrossLifeandHealthInsuranceCompanythatcannotberesolvedbyphone(whenappropriate)tothemutualsatisfactionofthememberandAnthemBlueCrossLifeandHealthInsuranceCompanywillbeacknowledgedinwriting,togetherwithadescriptionofhowAnthemBlueCrossLifeandHealthInsuranceCompanyproposestoresolvethegrievance.Grievancesthatcannotberesolvedbytheseproceduresshallberesolvedasindicatedthroughbindingarbitration,oriftheplanyouarecoveredunderissubjecttotheEmployeeRetirementIncomeSecurityActof1974(ERISA),incompliancewithERISArules.IfthegroupissubjecttoERISA,andamemberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sproposedresolutionofagrievance,themembermaysubmitanappealbyphoneorinwritingbycontactingthephonenumberoraddressprintedontheletterheadoftheAnthemBlueCrossLifeandHealthInsuranceCompanyresponseletter.
ForthepurposesofERISA,thereisonelevelofappeal.Forurgentcarerequestsforbenefits,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin72hoursfromthedatetheappealisreceived.Forpre-servicerequestsforbenefits,thememberwillreceivearesponsewithin30calendardaysfromthedatetheappealisreceived.Forpost-serviceclaims,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin60calendardaysfromthedatetheappealisreceived.
IfthememberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sdecisionontheappeal,themembermayelecttohavethedisputesettledthroughalternativeresolutionoptions,suchasvoluntarybindingarbitration.
Department of Insurance: Overseeingtheindustryandprotectingthestate’sinsuranceconsumersistheresponsibilityoftheCaliforniaDepartmentofInsurance(CDI).TheCDIregulates,investigatesandauditsinsurancebusinesstoensurethatcompaniesremainsolventandmeettheirobligationstoinsurancepolicyholders.Ifyouhaveaproblemregardingyourcoverage,pleasecontactAnthemBlueCrossfirsttoresolvetheissue.Ifcontactsbetweenyou(thecomplainant)andAnthemBlueCross(theInsurer)havefailedtoproduceasatisfactorysolutiontotheproblem,youmaywishtocontacttheCDI.TheycanbereachedbywritingtotheCaliforniaDepartmentofInsurance,ConsumerServicesDivision,300SouthSpringSt.-SouthTower,LosAngeles,CA90013.TheCDIalsohasatoll-freephonenumber800-927-HELP(4357)thatyoumaycallforassistance.
Binding Arbitration: IftheplanissubjecttoERISA,anydisputeinvolvinganadversebenefitdecisionmustberesolvedunderERISAclaimsprocedurerules,andisnotsubjecttomandatorybindingarbitration.MembersmaypursuevoluntarybindingarbitrationaftertheyhavecompletedanappealunderERISArules.Ifthememberhasanotherdisputethatdoesnotinvolveanadversebenefitdecision,orifthegroupdoesnotprovideaplanthatissubjecttoERISA,thenthememberandAnthemBlueCrossagreetobeboundbythearbitrationprovisionscontainedintheenrollmentformandCertificate.
Medicare: UnderTEFRA/DEFRA,Medicareistheprimarycoverageforgroupsoflessthan20employees.AnthemBlueCrosscoverageisconsideredprimarycoverageforgroupsof20ormoreemployees.ThisAnthemBlueCrosscoverageisnotasupplementtoMedicare,butprovidesbenefitsaccordingtothenon-duplicationofMedicareclause.
IfMedicareisamember’sprimaryhealthplan,AnthemBlueCrosswillnotprovidebenefitsthatduplicateanybenefitsyouareentitledtoreceiveunderMedicare.ThismeansthatwhenMedicareistheprimaryhealthcoverage,benefitsareprovidedinaccordancewiththebenefitsoftheplan,lessanyamountpaidbyMedicare.IfyouareentitledtoPartAandBofMedicare,youwillbeeligiblefornon-duplicateMedicarecoverage,withsupplementalcoordinationofbenefits.However,ifyouarerequiredtopaytheSocialSecurityAdministration
anadditionalpremiumforanypartofMedicare,thentheabovepolicywillonlyapplyifyouareenrolledinthatpartofMedicare.Note:Medicare-eligibleemployees/dependentsenrolledinplanswhereMedicareisprimarymayobtainanIndividualAnthemBlueCrossMedicareSupplementplanwiththepre-existingconditionexclusionwaived.
Specialty Pharmacy Program: Specialtymedicationsareusuallydispensedasaninjectabledrug,butmaybeavailableinotherforms,suchasapillorinhalant.Theyareusedtotreatcomplexconditions.Prescriptionsforaspecialtypharmacydrugarecoveredonlywhenorderedthroughthespecialtypharmacyprogram,unlessyouaregivenanexceptionfromthespecialtydrugprogram(seeyourCertificatefordetails).Thespecialtypharmacyprogramwilldeliveryourmedicationtoyoubymailorcommoncarrier(youcannotpickupyourmedication).
Youmayhavetopaythefullcostofaspecialtypharmacydrug,ifitisnotobtainedfromthespecialtypharmacyprogram.
Specialtydrugsarelimitedtoa30-daysupplyforeachfill.
Coordination of Benefits: Thebenefitsofamember’splanmaybereducedifthememberhasothergrouphealth,dental,drugorvisioncoverage,sothatbenefitsandservicesthememberreceivesfromallgroupcoveragesdonotexceed100percentofthecoveredexpense.
Third-Party Liability: Ifamemberisinjured,theresponsiblepartymaybelegallyobligatedtopayformedicalexpensesrelatedtothatinjury.AnthemBlueCrossmayrecoverbenefitspaidformedicalexpensesifthememberrecoversdamagesfromalegallyliablethirdparty.Examplesofthird-partyliabilitysituationsincludecaraccidentsandwork-relatedinjuries.
Voiding Coverage for False and Misleading Information: Falseormisleadinginformationorfailuretosubmitanyrequiredenrollmentmaterialsmayformthebasisforvoidingcoveragefromthedateaplanwasissuedorretroactivelyadjustingthepremiumtowhatitwouldhavebeenifthecorrectinformationhadbeenfurnished.Nobenefitswillbepaidforanyclaimsubmittedifcoverageismadevoid.Premiumsalreadypaidforthetimeperiodforwhichcoveragewasrescindedwillberefunded,minusanyclaimspaid.
Incurred Medical Care Ratio: Asrequiredbylaw,weareadvisingyouthatAnthemBlueCrossanditsaffiliatedcompanies’incurredmedicalcareratiofor2008was83.4percent.Thisratiowascalculatedafterproviderdiscountswereapplied.
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AGENT Guide
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Anthem Blue Cross is an NCQA Accredited health plan.Goods and services available through discount programs are not benefits of coverage. Anthem Blue Cross does not endorse or recommend any goods or services provided at a discount by these vendors or practitioners. These programs may be changed or withdrawn at any time without notice by the offering vendor or practitioner.
Solution 5000 PPO Plan is offered by Anthem Blue Cross Life and Health insurance Company.
Health care plans provided by Anthem Blue Cross. insurance plans provided by Anthem Blue Cross Life and Health insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. independent licensees of the Blue Cross Association. ® ANTHeM and 360° HeALTH are registered trademarks. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. The WebMd website is owned and operated by WebMd Health Corp. WebMd Health is solely responsible for its website and is not affiliated with Anthem Blue Cross or any affiliate of Anthem Blue Cross.
anthem.com/ca