Appeals & Grievances: This is a written or verbal expression of dissatisfaction about Anthem Blue Cross or Express Scripts (that administers the pharmacy benefit on behalf of Anthem) or Anthem Blue Cross or Express Scripts providers or an Anthem Blue Cross or Express Scripts vendor.
Balance Billing: A bill for the difference between the amount the plan reimburses for covered services—the allowable amount—and what an out-of-network provider chooses to charge. You are not required to pay this amount if you see an in-network provider.
Claim: A provider’s request to Anthem Blue Cross asking to be paid for a service you’ve received. Visit Submitting a Claim to learn more.
Copayment: A set dollar amount you pay for doctors’ visits, prescriptions and other covered health care services—only available when you see in-network, UC Select providers. Note: You may be charged separate copayments for services that involve multiple providers. For example, if you have an X-ray, you may be charged one copayment for taking the X-ray and a separate copayment for the radiologist to read it. To find a UC Select provider near you, visit anthem.com/ca. (Some services are not available in UC Select and are only available under Anthem Preferred. For more details, see UC Select.)
Deductible: The amount you pay out of pocket for health care each calendar year before the plan begins to share in the cost of covered services. There are separate deductibles for in- and out—of-network care. What you pay for one doesn’t count toward the other.
Prescription drug expenses are combined with the medical deductible so that what you pay for prescriptions counts toward the medical deductible.
Durable Medical Equipment (DME): Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
Eligibility: The benefits package available to you depends on the type of job you have, the percentage of time you work and the length of your appointment determine your benefits package. Visit UC Eligibility for more details.
Explanation of Benefits: After you get care, you’ll receive an Explanation of Benefits (EOB) from Anthem Blue Cross, the claims administrator. The EOB provides information about how your claim was paid, including how much you owe or will be reimbursed. Visit Reading Your EOB for more information.
Formulary: A list of drugs determined and maintained by Anthem to use for its prescription drug program. The formulary is designed to assist physicians in prescribing drugs that are medically necessary and cost effective. The formulary structure features generic medications (with the lowest copayments), preferred and non-preferred brands. It is updated periodically. If not otherwise excluded, the formulary includes all generic drugs. For current formularies, visit Anthem.
Generic drugs: Approved by the FDA as a therapeutic equivalent to the brand name drug. Most generic drugs are listed under “generic.” Drugs listed under generic have the same active ingredient as the brand name versions but at a lower cost. For more information about generic drugs and costs, visit Anthem.
Hospice services: Services provided to support end-of-life care when the patient’s condition is terminal and can no longer receive curative treatment. Support services are also provided to the patient’s family members.
In-network copayment: Available only when you see UC Select providers, this is a fixed amount (for example, $20) that you pay for covered health care services. To find a UC Select provider near you, visit anthem.com/ca/uc. (Some services are not available in UC Select and are only available under Anthem Preferred. For more details, see UC Select.
Network providers: A state-licensed health care provider who has contracted with a health care plan and has agreed to certain rates. In most cases, you pay less and receive a higher level of benefits when you use in-network providers (UC Select or Anthem Preferred). Check your plan for coverage details.
Out-of-network coinsurance: The percent (for example, 50%) you pay of the allowable amount for covered health care services to providers who do not contract with your health plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
There are separate out-of-pocket maximums for in- and out-of-network care. What you pay for one doesn’t count toward the other.
Prescription drug expenses are combined with the medical out-of-pocket maximums so that what you pay for prescriptions counts toward the medical out-of-pocket maximum.
Preauthorization: A decision by your health plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called “prior authorization,” “prior approval” or “precertification.” Your health or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health plan will cover the cost.
Preferred provider organization (PPO): A PPO is similar to a traditional “fee-for-service” plan, but you must use doctors in the PPO provider network or pay a higher coinsurance (percentage of charges). A PPO allows you to select most providers without a referral. In these plans, you typically must meet an annual deductible before some benefits apply. You are responsible for a certain coinsurance amount and the plan pays the balance up to the allowable amount. As a PPO health plan member, you get maximum benefit coverage when you use the PPO network of physicians and hospitals.
Premium: Your health care costs begin with your premium—the amount that’s deducted from your paycheck for your coverage, depending on your salary band. Visit UC Employee Medical Plan Costs to find your current monthly premium.
Preventive care: You have access to preventive services through your medical plan at no cost to you if a participating provider is used and the claims they submit are coded correctly. The types of preventive services covered generally must have been rated as an A or B service by the U.S. Preventive Services Task Force, although the medical plan you are enrolled in may cover additional preventive services that did not receive this rating. Follow-up testing for a diagnosed medical condition (such as additional glucose or cholesterol level tests) will generally not be covered as preventive. These services are covered for men, women and children:
- Annual well-adult and well-woman exams
- Well-baby and well-child visits based on American Academy of Pediatrics and the American Academy of Family Physicians age and frequency guidelines
- Blood pressure, diabetes and cholesterol tests based on age and gender guidelines
- Routine mammograms and cervical cancer screening, included PAP smears
- Colorectal cancer screenings, including fecal occult blood testing, sigmoidoscopy, or colonoscopy based on age guidelines
- Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
- Routine vaccinations against diseases such as measles, polio, or meningitis.
- Flu and pneumonia shots
- Counseling, screening and vaccines to ensure healthy pregnancies
- Women’s preventive services:
- Breast feeding support, supplies, and counseling, including breast pumps
- Contraception counseling
- Contraception methods (IUDs and diaphragms)
- Domestic violence screening
- Gestational diabetes screening
- HIV screening and counseling
- Human papillomavirus testing (beginning at age 30, and for every three years thereafter)
- Sexually transmitted infections and counseling
Primary care provider: A physician (M.D.—Medical Doctor or D.O.—Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Rehabilitation services: Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled nursing care: Services from licensed nurses in your own home or in a skilled nursing facility. Skilled care services are from licensed technicians and therapists in your own home or in a nursing facility.
Specialist: A physician specialist who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Specialty Medications: These are drugs that are used to treat complex or chronic conditions that usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer and other conditions that are difficult to treat with traditional therapies. Specialty drugs may be self-administered in the home by injection (under the skin or into a muscle), by inhalation, by mouth or on the skin. These drugs may also require special handling, special manufacturing processes and may have limited prescribing or limited pharmacy availability. Specialty drugs are obtained from the Anthem specialty pharmacy–Accredo, and may require prior authorization.
Step Therapy Program: Step therapy requires members to try preferred medications as the initial step in treatment before select non-preferred medications are covered. Preferred medications included in the program are widely recognized as clinically safe and effective. This program can lower both plan and member costs, while still providing access to non-preferred medications.