Begin cover bc life cover

SAN BERNARDINO MUNICIPAL WATER
January 1, 2016 Prescription Drug
WL277251-4 0416 Custom Assurance 1 Rx Plan 10/20/35/25% COMPLAINT NOTICE
Should you have any complaints or questions regarding your
coverage, and this certificate was delivered by a broker, you should
first contact the broker. You may also contact us at:
Anthem Blue Cross Life and Health Insurance Company
Customer Service
21555 Oxnard Street
Woodland Hills, CA 91367
If the problem is not resolved, you may also contact the California
Department of Insurance at:
California Department of Insurance
Claims Service Bureau, 11th Floor
300 South Spring Street
Los Angeles, California 90013
1-800-927-HELP (4357) – In California
1-213-897-8921 – Out of California
1-800-482-4833 – Telecommunication Device for the Deaf
E-mail Inquiry:
"Consumer Services" link at
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. CERTIFICATE OF INSURANCE
Anthem Blue Cross Life and Health Insurance Company
21555 Oxnard Street
Woodland Hills, California 91367
This Certificate of Insurance, including any amendments and
endorsements to it, is a summary of the important terms of your
health plan. It replaces any older certificates issued to you for the
coverages described in the Summary of Benefits. The Group
Policy, of which this certificate is a part, must be consulted to
determine the exact terms and conditions of coverage. If you have
special health care needs, you should read those sections of the
Certificate of Insurance that apply to those needs. Your employer
will provide you with a copy of the Group Policy upon request.

Your health care coverage is insured by Anthem Blue Cross Life and
Health Insurance Company (Anthem Blue Cross Life and Health). The
following pages describe your health care benefits and includes the
limitations and all other policy provisions which apply to you. The
insured person is referred to as "you" or "your," and Anthem Blue Cross
Life and Health as "we," "us" or "our." Al italicized words have specific
policy definitions. These definitions can be found in the DEFINITIONS
section of this certificate.
TABLE OF CONTENTS
WL277251-4 0416 Custom Assurance 1 Rx Plan 10/20/35/25% WL277251-4 0416 Custom Assurance 1 Rx Plan 10/20/35/25% TYPES OF PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL
KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS
OUTPATIENT PRESCRIPTION DRUGS MAY BE OBTAINED. THE
MEANINGS OF WORDS AND PHRASES IN ITALICS ARE
DESCRIBED IN THE SECTION OF THIS BOOKLET ENTITLED
DEFINITIONS.
Participating and Non-Participating Pharmacies. "Participating
Pharmacies" agree to charge only the prescription drug maximum
allowed amount to fill the prescription. You pay only your co-payment
amount.
"Non-Participating Pharmacies" have not agreed to the prescription drug maximum allowed amount. The amount that will be covered as prescription drug covered expense is significantly lower than what these providers customarily charge. SUMMARY OF BENEFITS
THE BENEFITS OF THIS CERTIFICATE ARE PROVIDED ONLY FOR
OUTPATIENT PRESCRIPTION DRUGS WHICH ARE CONSIDERED
TO BE MEDICALLY NECESSARY. THE FACT THAT A PHYSICIAN
PRESCRIBES OR ORDERS THE SERVICE DOES NOT, IN ITSELF,
MAKE IT MEDICALLY NECESSARY OR A COVERED EXPENSE.
This summary provides a brief outline of your benefits. You need to refer to the entire certificate for complete information about the benefits, conditions, limitations and exclusions of your plan. The benefits of this plan may be subject to the REIMBURSEMENT FOR ACTS OF THIRD PARTIES section. PRESCRIPTION DRUG BENEFITS
PRESCRIPTION DRUG CO-PAYMENTS. The following co-payments
apply for each prescription:
Retail Pharmacies: The following co-payments apply for a 30-day
supply of medication. Note: Specified specialty drugs must be obtained
through the specialty pharmacy program. However, the first two month
supply of a specialty drug may be obtained through a retail pharmacy,
after which the drug is available only through the specialty pharmacy
program unless an exception is made.
Participating Pharmacies
 Tier 1 drugs . $10
 Diabetic Supplies . $10
 Tier 2 drugs . $20
 Tier 3 drugs . $35
 Compound Medications . $35
 Tier 4 drugs . 25%

of the prescription drug maximum allowed amount to a maximum co-payment of $150
Please note that presentation of a prescription to a pharmacy or
pharmacist does not constitute a claim for benefit coverage. If you
present a prescription to a participating pharmacy, and the participating
pharmacy indicates your prescription cannot be filled, your deductible, if
any, needs to be satisfied, or requires an additional Co-Payment, this is
not considered an adverse claim decision. If you want the prescription
filled, you will have to pay either the full cost, or the additional Co-Payment, for the prescription drug. If you believe you are entitled to some plan benefits in connection with the prescription drug, submit a claim for reimbursement to the pharmacy benefits manager. Non-Participating Pharmacies*
 Tier 1 drugs . $10

plus 50% of the
remaining prescription drug maximum allowed amount  Diabetic Supplies . $10

plus 50% of the
remaining prescription drug maximum allowed amount  Tier 2 drugs . $20

plus 50% of the
remaining prescription drug maximum allowed amount  Tier 3 drugs . $35

plus 50% of the
remaining prescription drug maximum allowed amount  Tier 4 drugs . 25%

of the prescription drug maximum allowed amount to a maximum co-payment of $150 plus 50% of the
remaining prescription drug maximum allowed amount Home Delivery Prescriptions: The following co-payments apply for a
90-day supply of medication.
 Tier 1 drugs . $15
 Diabetic Supplies . $15
 Tier 2 drugs . $30
 Tier 3 drugs . $50
 Tier 4 drugs . 25%

of the prescription drug maximum allowed amount to a maximum co-payment of $300
Exceptions to Prescription Drug Co-payments
 "Preventive Prescription Drugs and Other Items" covered under YOUR PRESCRIPTION
DRUG BENEFITS . No charge
Prescription Drug Out-of-Pocket Amount
After you pay $3,500 in co-payments for your Tier 4 drugs in one year for
your drugs, you will have reached the Prescription Drug Out-of-Pocket
Amount and you will not need to pay any more co-payments for those
types of drugs the rest of the year.
After we determine that you have reached the Prescription Drug Out-of-Pocket Amount, we will let the participating pharmacies know that you do not need to pay co-payments for the rest of the calendar year for your Tier 4 drugs. *Important Note About Prescription Drug Covered Expense and
Your Co-Payment.
The prescription drug formulary is a list of outpatient prescription drugs which may be particularly cost-effective, therapeutic choices. Your co-payment amount for non-formulary drugs is higher than for formulary drugs. Any participating pharmacy can assist you in purchasing a formulary drug. You may also get information about covered formulary drugs by calling 1-800-700-2541 (or TTY/TDD 1-800-905-9821) or going to our internet websi What we allow for prescription drug covered expense for non-participating pharmacies is usually significantly lower than what those providers customarily charge, so you will almost always have a higher out-of-pocket expense for your drugs when you use a non-participating pharmacy to fill your prescription. YOU WILL BE REQUIRED TO PAY YOUR CO-PAYMENT AMOUNT
TO THE PARTICIPATING PHARMACY AT THE TIME YOUR
PRESCRIPTION IS FILLED.
Note: If your pharmacy's retail price for a drug is less than the co-
payment shown above, you will not be required to pay more than that
retail price.
Preferred Generic Program
Prescription drugs will always be dispensed by a pharmacist as prescribed by your physician. Your physician may order a drug in a higher or lower drug co-payment tier for you. You may request your physician to prescribe a drug in a higher drug co-payment tier instead of a drug in a lower co-payment tier or you may request the pharmacist to give you a drug in a higher copay tier instead of a drug in a lower copay tier. Under this plan, if a drug is available in a lower co-payment drug tier, and it is not determined that a drug in a higher co-payment drug tier is medically necessary for you to have (see PRESCRIPTION DRUG FORMULARY: PRIOR AUTHORIZATION below), you will have to pay the co-payment for the lower tier drug plus the difference in cost between the prescription drug maximum allowed amount for the lower co-payment drug tier and the higher co-payment drug tier, but, not more than 50% of our average cost for the tier that the drug is in. If your physician specifies "dispense as written," in lieu of paying the co-payment for the lower tier drug plus the difference, as previously stated, you will pay just the applicable co-payment shown for the higher tier drug you get. 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, home delivery 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 physician to take "½ tablet daily" of those medications on an list approved by us. The Pharmacy and Therapeutics Process 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 physician. To obtain a list of the products available on this program call 1-800-700-2541 (or TTY/TDD YOUR PRESCRIPTION DRUG BENEFITS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL
KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS
OUTPATIENT PRESCRIPTION DRUGS MAY BE OBTAINED. THE
MEANINGS OF WORDS AND PHRASES IN ITALICS ARE
DESCRIBED IN THE SECTION OF YOUR CERTIFICATE ENTITLED
DEFINITIONS.
PRESCRIPTION DRUG COVERED EXPENSE
Prescription drug covered expense is the maximum charge for each covered service or supply that will be accepted by us for each different type of pharmacy. It is not necessarily the amount a pharmacy bills for the service. You may avoid higher out-of-pocket expenses by choosing a participating pharmacy, or by utilizing the home delivery program whenever possible. In addition, you may also reduce your costs by asking your physician, and your pharmacist, for the more cost-effective generic form of prescription drugs. Prescription drug covered expense will always be the lesser of the billed charge or the prescription drug maximum allowed amount. Expense is incurred on the date you receive the drug for which the charge is made. When you choose a participating pharmacy, the pharmacy benefits manager will subtract any expense which is not covered under your prescription drug benefits. The remainder is the amount of prescription drug covered expense for that claim. You will not be responsible for any amount in excess of the prescription maximum allowed amount for the covered services of a participating pharmacy. When the pharmacy benefits manager receives a claim for drugs supplied by a non-participating pharmacy, they first subtract any expense which is not covered under your prescription drug benefits, and then any expense exceeding the prescription maximum allowed amount. The remainder is the amount of prescription drug covered expense for that claim. You will always be responsible for expense incurred which is not
covered under this plan.
PRESCRIPTION DRUG CO-PAYMENTS AND PRESCRIPTION DRUG
OUT-OF-POCKET AMOUNTS
CO-PAYMENTS
After the pharmacy benefits manager determines prescription drug covered expense, they will subtract your Prescription Drug Co-Payment for each prescription. If your Prescription Drug Co-Payment includes a percentage of prescription drug covered expense, then the pharmacy benefits manager will apply that percentage to such expense. This will determine the dollar amount of your Prescription Drug Co-Payment. PRESCRIPTION DRUG OUT-OF-POCKET AMOUNT
If you pay Prescription Drug Co-Payments equal to your Prescription Drug Out-of-Pocket Amount per insured person during a calendar year, you will no longer be required to make Co-Payments for any drug covered expense you incur during the remainder of that calendar year. The Prescription Co-Payments and Prescription Drug Out-of-Pocket Amounts are set forth in the SUMMARY OF BENEFITS. HOW TO USE YOUR PRESCRIPTION DRUG BENEFITS
When You Go to a Participating Pharmacy. To identify you as an
insured person covered for prescription drug benefits, you will be issued
an identification card. You must present this card to participating
pharmacies when you have a prescription filled. Provided you have
properly identified yourself as an insured person, a participating
pharmacy will only charge your Co-Payment. For information on how to
locate a participating pharmacy in your area, call 1-800-700-2541 (or
TTY/TDD 1-800-905-9821).
Generic drugs will be dispensed by participating pharmacies when the prescription indicates a generic drug. When a brand name drug is specified, but a generic drug equivalent exists, the generic drug will be substituted. Brand name drugs will be dispensed by participating pharmacies when the prescription specifies a brand name and states "dispense as written" or no generic drug equivalent exists. Please note that presentation of a prescription to a pharmacy or
pharmacist does not constitute a claim for benefit coverage. If you
present a prescription to a participating pharmacy, and the participating
pharmacy indicates your prescription cannot be filled, or requires an
additional Co-Payment, this is not considered an adverse claim decision.
If you want the prescription filled, you will have to pay either the full cost,
or the additional Co-Payment, for the prescription drug. If you believe
you are entitled to some plan benefits in connection with the prescription drug, submit a claim for reimbursement to us at the address shown below: Prescription Drug Program
ATTN: Commercial Claims
P.O. Box 2872
Clinton, IA 52733-2872
Participating pharmacies usually have claims forms, but, if the participating pharmacy does not have claim forms, claim forms and customer service are available by calling 1-800-700-2541 (or TTY/TDD 1-800-905-9821). Mail your claim, with the appropriate portion completed by the pharmacist, to the pharmacy benefits manager within 90 days of the date of purchase. If it is not reasonably possible to submit the claim within that time frame, an extension of up to 12 months will be allowed. When You Order Your Prescription Through Specialty Drug
Program. Certain specified specialty drugs must be obtained through
the specialty pharmacy program unless you are given an exception from
the specialty drug program (see PRESCRIPTION DRUG CONDITIONS OF
SERVICE). These specified specialty drugs that must be obtained through
the Specialty Drug Program are limited to up to a 30-day supply. The
Specialty Drug Program will deliver your medication to you by mail or
common carrier (you cannot pick up your medication at Anthem Blue
Cross Life and Health).
The prescription for the specialty drug must state the drug name, dosage, directions for use, quantity, the physician's name and phone number, the patient's name and address, and be signed by a physician. You or your physician may order your specialty drug by calling 1-800-700-2541. When you call the Specialty Drug 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 use a credit card or debit card to pay for it.) 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 Specialty Drug Program. Once you have met your deductible, if any, you will only have to pay the cost of your Co-Payment. With few exceptions, most orally administered anti-cancer medications are considered specialty drugs. For orally administered anti-cancer medications, the prescription drug deductible, if any, will not apply and the copayment will not exceed the lesser of the applicable copayment shown in the SUMMARY OF BENEFITS or $200 for a 30-day supply for medications obtained at a retail pharmacy or $600 for a 90-day supply for medications obtained through home delivery. The first time you get a prescription for a specialty drug you must also include a completed Intake Referral Form. The Intake Referral Form is to be completed 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. Co-payments can be made by check, money order, credit card or debit card. You or your physician may obtain order forms or a list of specialty drugs that must be obtained through specialty pharmacy program by contacting Member Services at the number listed on your ID card or online at Specified specialty drugs must be obtained through the Specialty
Pharmacy Program. When these specified specialty drugs are not
obtained through the Specialty Pharmacy Program, and you do not
have an exception, you will not receive any benefits for these drugs
under this plan.
When You Go to a Non-Participating Pharmacy. If you purchase a
prescription drug from a non-participating pharmacy, you will have to pay
the full cost of the drug and submit a claim to us, at the address below:
Prescription Drug Program
ATTN: Commercial Claims
P.O. Box 2872
Clinton, IA 52733-2872
Non-participating pharmacies do not have our prescription drug claim forms. You must take a claim form with you to a non-participating pharmacy. The pharmacist must complete the pharmacy's portion of the form and sign it. Claim forms and customer service are available by calling 1-800-700-2541 (or TTY/TDD 1-800-905-9821). Mail your claim with the appropriate portion completed by the pharmacist to us within 90 days of the date of purchase. If it is not reasonably possible to submit the claim within that time frame, an extension of up to 12 months will be allowed. When You are Out of State. If you need to purchase a prescription
drug out of the state of California, you may locate a participating
pharmacy by calling 1-800-700-2541. If you cannot locate a participating
pharmacy, you must pay for the drug and submit a claim to us. (See
"When You Go to a Non-Participating Pharmacy" above.)

When You Order Your Prescription Through the Home Delivery
Program. You can order your prescription through the home delivery
prescription drug program. Not all medications are available through the
home delivery pharmacy.
The prescription must state the drug name, dosage, directions for use, quantity, the physician's name and phone number, the patient's name and address, and be signed by a physician. You must submit it with the appropriate payment for the amount of the purchase, and a properly completed order form. You need only pay the cost of your Co-Payment. Your first home delivery prescription must also include a completed Patient Profile questionnaire. The Patient Profile questionnaire can be obtained by calling the toll-free number shown on your ID card. You need only enclose the prescription or refill notice, and the appropriate payment for any subsequent home delivery prescriptions, or call the toll-free number. Co-payments can be paid by check, money order or credit card. Order forms can be obtained by contacting us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821) to request one. The form is also available on-line ata. PRESCRIPTION DRUG UTILIZATION REVIEW
Your prescription drug benefits include utilization review of prescription drug usage for your health and safety. Certain drugs may require prior authorization. If there are patterns of over-utilization or misuse of drugs, our medical consultant will notify your personal physician and your pharmacist. We reserve the right to limit benefits to prevent over-utilization of drugs. PRESCRIPTION DRUG FORMULARY
We use a prescription drug formulary to help your physician make prescribing decisions. The presence of a drug on the plan's prescription drug formulary list does not guarantee that you will be prescribed that drug by your physician. This list of outpatient prescription drugs is developed by a committee of physicians and pharmacists to determine which medications are sound, therapeutic and cost effective choices. These medications, which include both generic and brand name drugs, are listed in the prescription drug formulary. The committee updates the formulary quarterly to ensure that the list includes drugs that are safe and effective. Note: The formulary drugs may change from time to time. Some drugs may require prior authorization. If you have a question regarding whether a particular drug is on our formulary drug list or requires prior authorization please call us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821). Information about the drugs on our formulary drug list is also available on our internet website www.anthem.com/ca. Prior Authorization. Certain drugs require written prior authorization of
benefits in order for you to receive benefits. Prior authorization criteria
will be based on medical policy and the Pharmacy and Therapeutics
Process established guidelines. You may need to try a drug other than
the one originally prescribed if we determine that it should be clinically
effective for you. However, if we determine through prior authorization
that the drug originally prescribed is medically necessary, you will be
provided the drug originally requested at the applicable co-payment. (If,
when you first become an insured person, you are already being treated
for a medical condition by a drug that has been appropriately prescribed
and is considered safe and effective for your medical condition, and you
underwent a prior authorization process under the prior plan which
required you to take different drugs, we will not require you to try a drug
other than the one you are currently taking.) If approved, drugs requiring
prior authorization for benefits will be provided to you after you make the
required co-payment.
In order for you to get a drug that requires prior authorization, your physician must send a written request to us for the drug. The request can be sent to us by mail, facsimile, or it may be submitted electronically. If your physician needs a copy of the request form, he or she may call us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821) to request one. The form is also available on-line aa. We will review the request and respond within two business days of receiving the completed authorization request form. If material information necessary to approve or disapprove the request is missing, we will tell your physician within two business days. While we are reviewing the request, a 72-hour emergency supply of medication may be dispensed to you if your physician or pharmacist determines that it is appropriate and medically necessary. You may have to pay the applicable co-payment shown in SUMMARY OF BENEFITS: PRESCRIPTION DRUG BENEFITS: PRESCRIPTION DRUG CO-PAYMENTS for the 72-hour supply of your drug. If we approve the request for the drug after you have received a 72-hour supply, you will receive the remainder of the 30-day supply of the drug with no additional copayment. If you have any questions regarding whether a drug is on our prescription drug formulary, or requires prior authorization, please call us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821). Information about the drugs on our formulary drug list is also available on our internet website www.anthem.com/ca. If we deny a request for prior authorization of a drug that is not part of our formulary drug list, you or your prescribing physician may appeal our decision by calling us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821). If you are dissatisfied with the resolution of your inquiry and want to file a grievance, you may write us at Anthem Blue Cross Life and Health Insurance Company, 21555 Oxnard Street, Woodland Hills, CA 91367, and follow the formal grievance process. Revoking or modifying a prior authorization. A prior authorization of
benefits for prescription drugs may be revoked or modified prior to your
receiving the drugs for reasons including but not limited to the following:
 Your coverage under this plan ends;  The policy with the group terminates;  You reach a benefit maximum that applies to prescription drugs, if the plan includes such a maximum;  Your prescription drug benefits under the plan change so that prescription drugs are no longer covered or are covered in a different way. A revocation or modification of a prior authorization of benefits for prescription drugs applies only to unfilled portions or remaining refills of the prescription, if any, and not to drugs you have already received. New drugs and changes in the prescription drugs covered by the
plan. The outpatient prescription drugs included on the list of formulary
drugs covered by the plan is decided by the Pharmacy and Therapeutics
Process, which is comprised of independent nurses, physicians and
pharmacists. The Pharmacy and Therapeutics Process meets quarterly
and decides on changes to make in the formulary drug list based on
recommendations from us and a review of relevant information, including
current medical literature.
PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS
Your prescription drug benefits include certain preventive drugs, medications, and other items as listed below that may be covered under this plan as preventive care services. In order to be covered as a preventive care service, these items must be prescribed by a physician and obtained from a participating pharmacy or through the home delivery program. This includes items that can be obtained over the counter for which a physician's prescription is not required by law. When these items are covered as preventive care services, the Calendar Year Deductible, if any, will not apply and no co-payment will apply. In addition, any separate deductible that applies to prescription drugs will not apply.  All FDA-approved contraceptives for women, including oral over-the-counter contraceptives. In order to be covered as a preventive care service, in addition to the requirements stated above, contraceptive prescription drugs must be generic drugs or single source brand name drugs.  Shingles, seasonal flu and pneumonia vaccinations.  Prescription drugs to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products.  FDA-approved smoking cessation products including over-the- counter nicotine replacement products when obtained with a physician's prescription and you are at least 18 years old.  Aspirin to reduce the risk of heart attack or stroke, for men ages 45- 79 and women ages 55-79.  Folic acid supplementation for women age 55 years and younger (folic acid supplement or a multivitamin).  Vitamin D for women over age 65.  Medications for risk reduction of primary breast cancer in women (such as tamoxifen or raloxifene) for women who are at increased risk for breast cancer and at low risk for adverse medication effects.  Iron supplements for children from birth through 12 months old.  Fluoride supplements for children from birth through 6 years old (drops or tablets). PRESCRIPTION DRUG CONDITIONS OF SERVICE
To be covered, the drug or medication must satisfy all of the following requirements: 1. It must be prescribed by a licensed prescriber and be dispensed within one year of being prescribed, subject to federal and state laws. This requirement will not apply to covered vaccinations provided at a participating pharmacy. 2. It must be approved for general use by the Food and Drug Administration (FDA). 3. It must be for the direct care and treatment of your illness, injury or condition. Dietary supplements, health aids or drugs for cosmetic purposes are not included. However the following items are covered: a. Formulas prescribed by a physician for the treatment of phenylketonuria. b. Vaccinations provided at a participating pharmacy as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS, subject to all terms of this plan that apply to those benefits. c. Vitamins, supplements, and health aids as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS, subject to all terms of this plan that apply to those benefits. 4. It must be dispensed from a licensed retail pharmacy, through our home delivery program or through our specialty drug program. 5. If it is an approved compound medication, be dispensed by a
participating pharmacy. Call 1-800-700-2541 (or TTY/TDD 1-800-
905-9821) to find out where to take your prescription for an approved
compound medication to be filled. (You can also find a participating
pharmacy Some compound medications
must be approved before you can get them (See PRESCRIPTION
DRUG FORMULARY: PRIOR AUTHORIZATION). You will have to pay the
full cost of the compound medications you get from a pharmacy
that is not a participating pharmacy.
6. If it is a specified specialty drug, be obtained by using the
specialty drug program. See the section HOW TO USE YOUR
PRESCRIPTION DRUG BENEFITS: WHEN YOU ORDER YOUR PRESCRIPTION
THROUGH SPECIALTY DRUG PROGRAM for how to get your drugs by
using the specialty drug program. You will have to pay the full
cost of any specialty drugs you get from a retail pharmacy that
you should have obtained from the specialty drug program. If
you order a specialty drug that must be obtained using the
specialty pharmacy program through the home delivery
program, it will be forwarded to the specialty drug program for
processing and will be processed according to specialty drug
program rules.
Exceptions to specialty drug program. This requirement does not
apply to:
a. The first two month's supply of a specified specialty drug which is available through a participating retail pharmacy; or b. Drugs, which due to medically necessity, must be obtained c. An insured person who is unable to pay for delivery of their medication (i.e., no credit card); or d. An insured person for whom, according to the Coordination of Benefit rules, this plan is not the primary plan. How to obtain an exception to the specialty drug program. If you
believe that you should not be required to get your medication
through the specialty drug program, for any of the reasons listed
above, except for d., you must complete an Exception to Specialty
Drug Program form to request an exception and send it to us. The
form can be faxed or mailed to us. If you need a copy of the form,
you may call us at 1-800-700-2541 (or TTY/TDD 1-800-905-9821) to
request
If we have given you an exception, it will be good for a limited period of time based on the reason for the exception. When the exception period ends, if you believe that you should still not be required to get your medication through the specialty drug program, you must again request an exception. If we deny your request for an exception, it will be in writing and will tell you why we did not approve the exception. Urgent or emergency need of a specialty drug subject to the
specialty drug program. If you are out of a specialty drug which
must be obtained through the specialty drug program, we will
authorize an override of the specialty drug program requirement for
72-hours, or until the next business day following a holiday or
weekend, to allow you to get an emergency supply of medication if
your doctor decides that it is appropriate and medically necessary.
You may have to pay the applicable co-payment shown SUMMARY OF
BENEFITS: PRESCRIPTION DRUG BENEFITS: PRESCRIPTION DRUG CO-
PAYMENTS for the 72-hour supply of your drug.
If you order your specialty drug through the specialty drug program and it does not arrive, if your physician decides that it is medically necessary for you to have the drug immediately, we will authorize an override of the specialty drug program requirement for 30-day supply or less, to allow you to get an emergency supply of medication from a participating pharmacy near you. A Dedicated Care Coordinator from the specialty drug program will coordinate the exception and you will not be required to make an additional co-payment. 7. It must not be used while you are confined in a hospital, skilled nursing facility, rest home, sanitorium, convalescent hospital, or similar facility. Also, it must not be dispensed in or administered by a hospital, skilled nursing facility, rest home, sanitorium, convalescent hospital, or similar facility. Other drugs that may be prescribed by your physician while you are confined in a rest home, sanitarium, convalescent hospital or similar facility, may be purchased at a pharmacy by the member, or a friend, relative or care giver on your behalf, and are covered under this prescription drug benefit. 8. For a retail pharmacy or specialty drug program, the prescription must not exceed a 30-day supply. Prescription drugs federally-classified as Schedule II which are FDA-approved for the treatment of attention deficit disorder must not exceed a 60-day supply. If the physician prescribes a 60-day supply for drugs classified as Schedule II for the treatment of attention deficit disorders, the insured person has to pay double the amount of co-payment for retail pharmacies. If the drugs are obtained through the home delivery program, the co-payment will remain the same as for any other prescription drug. FDA-approved smoking cessation products and over-the-counter nicotine replacement products are limited as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS. 9. Certain drugs have specific quantity supply limits based on our analysis of prescription dispensing trends and the Food and Drug Administration dosing recommendations. 10. For the home delivery program, the prescription must not exceed a 11. The drug will be covered under YOUR PRESCRIPTION DRUG BENEFITS only if it is not covered under another benefit of your plan. 12. Drugs for the treatment of impotence and/or sexual dysfunction are limited to six tablets/units for a 30-day period and are available at retail pharmacies only. Documented evidence of contributing medical condition must be submitted to us for review. PRESCRIPTION DRUG SERVICES AND
SUPPLIES THAT ARE COVERED
1. Outpatient drugs and medications which the law restricts to sale by prescription, except as specifically stated in this section. Formulas prescribed by a physician for the treatment of phenylketonuria. These formulas are subject to the copayment for brand name drugs. 3. Syringes when dispensed for use with insulin and other self- injectable drugs or medications. 4. Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member. Drugs with Food and Drug Administration (FDA) labeling for self-administration. 5. All compound prescription drugs when a commercially available dosage form of a medically necessary medication is not available, all the ingredients of the compound drug are FDA approved, a prescription to dispense is required, and the compound drug is not essentially the same as an FDA approved product from a drug manufacturer. Non-FDA approved non-proprietary, multisource ingredients that are vehicles essential for compound administration may be covered. 6. Diabetic supplies (i.e. test strips and lancets). 7. Inhaler spacers and peak flow meters for the treatment of pediatric asthma. These items are subject to the copayment for brand name drugs. 8. Prescription drugs, vaccinations, vitamins, supplements, and certain over-the-counter PRESCRIPTION DRUGS AND OTHER ITEMS, subject to all terms of this plan that apply to those benefits. 9. Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. PRESCRIPTION DRUG SERVICES AND
SUPPLIES THAT ARE NOT COVERED
In addition to the exclusions and limitations listed under YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS NOT COVERED, prescription drug benefits are not provided for or in connection with the following: 1. Immunizing agents, biological sera, blood, blood products or blood plasma. While not covered under this prescription drug benefit, these items are covered under [IMAG] of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. This exclusion will not apply to vaccinations listed as covered under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS, or to those listed as covered by the PreventiveRx program, if included, provided at a participating pharmacy. 2. Hypodermic syringes and/or needles except when dispensed for use with insulin and other self-injectable drugs or medications. While not covered under this prescription drug benefit, these items are covered under [HYSY] of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 3. Drugs and medications used to induce spontaneous and non- spontaneous abortions. While not covered under this prescription drug benefit, FDA approved medications that may only be dispensed by or under direct supervision of a physician, such as drugs and medications used to induce non-spontaneous abortions, are covered as specifically stated in the "Prescription Drug for Abortion" provision of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to the benefit. 4. Drugs and medications dispensed or administered in an outpatient setting; including, but not limited to, outpatient hospital facilities and physicians' offices. While not covered under this prescription drug benefit, these services are covered as specified under [[DRME] of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 5. Professional charges in connection with administering, injecting or dispensing of drugs. While not covered under this prescription drug benefit, these services are covered as specified under [PC] of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 6. Drugs and medications which may be obtained without a physician's written prescription, except insulin or niacin for cholesterol reduction. Note: Vitamins, supplements, and certain over-the-counter items as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS are covered under this plan only when obtained with a physician's prescription, subject to all terms of this plan that apply to those benefits. 7. Drugs and medications dispensed by or while you are confined in a hospital, skilled nursing facility, rest home, sanitarium, convalescent hospital, or similar facility. While not covered under this prescription drug benefit, such drugs are covered as specified under the "Hospital", "Skil ed Nursing Facility", and "Hospice Care", provisions of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. While you are confined in a rest home, sanitarium, convalescent hospital or similar facility, drugs and medications supplied and administered by your physician are covered as specified under the "Professional Services" provision of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to the benefit. Other drugs that may be prescribed by your physician while you are confined in a rest home, sanitarium, convalescent hospital or similar facility, may be purchased at a pharmacy by the insured person, or a friend, relative or care giver on your behalf, and are covered under this prescription drug benefit. 8. Durable medical equipment, devices, appliances and supplies, even if prescribed by a physician, except prescription contraceptives as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS. While not covered under this prescription drug benefit, these items are covered as specified under the "Durable Medical Equipment", "Hearing Aid Services", and "Diabetes" provisions of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 9. Services or supplies for which you are not charged. 10. Oxygen. While not covered under this prescription drug benefit, oxygen is covered as specified under the "Hospital", "Skil ed Nursing Facility", "Home Health Care" and "Hospice Care" provisions of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 11. Cosmetics and health or beauty aids. However, health aids that are medically necessary and meet the requirements for durable medical equipment as specified under the "Durable Medical Equipment" provision of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), are covered, subject to all terms of this plan that apply to that benefit. 12. Drugs labeled "Caution, Limited by Federal Law to Investigational Use" or Non-FDA approved investigational drugs. Any drugs or medications prescribed for experimental indications. If you are denied a drug because we determine that the drug is experimental or investigative, you may ask that the denial be reviewed by an external independent medical review organization. (See the section "Independent Medical Review of Denials of Experimental or Investigative Treatment" (see Table of Contents) for how to ask for a review of your drug denial.) 13. Any expense incurred for a drug or medication in excess of: prescription drug maximum allowed amount. 14. Drugs which have not been approved for general use by the Food and Drug Administration. This does not apply to drugs that are medically necessary for a covered condition. 15. Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is cosmetic. 16. Drugs used primarily for the purpose of treating infertility (including but not limited to Clomid, Pergonal, and Metrodin) unless medically necessary for another covered condition. 17. Anorexiants and drugs used for weight loss except when used to treat morbid obesity (e.g., diet pills and appetite suppressants).This exclusion does not apply to drugs used for weight loss which are listed as covered under the PreventiveRx program, if included. 18. Drugs obtained outside of the United States unless they are furnished in connection with urgent care or an emergency. 19. Allergy desensitization products or allergy serum. While not covered under this prescription drug benefit, such drugs are covered as specified under the "Hospital", "Skil ed Nursing Facility", and "Professional Services" provisions of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. self-administered subcutaneously. While not covered under this prescription drug benefit, infusion drugs are covered as specified under the [INFU] of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to those benefits. 21. Herbal supplements, nutritional and dietary supplements. However, formulas prescribed by a physician for the treatment of phenylketonuria that are obtained from a pharmacy are covered as specified under PRESCRIPTION DRUG SERVICES AND SUPPLIES THAT ARE COVERED. Special food products that are not available from a pharmacy are covered as specified under the "Special Food Products" provision of YOUR MEDICAL BENEFITS: MEDICAL CARE THAT IS COVERED (see Table of Contents), subject to all terms of this plan that apply to the benefit. Also, vitamins, supplements, and certain over-the-counter items as specified under PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS are covered under this plan only when obtained with a physician's prescription, subject to all terms of this plan that apply to those benefits. 22. Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except insulin. This does not apply if an over-the-counter equivalent was tried and was ineffective. 23. Compound medications unless all the ingredients are FDA-approved and require a prescription to dispense, and the compound
medication is not essentially the same as an FDA-approved product
from a drug manufacturer. Exceptions to non-FDA approved
compound ingredients may include multi-source, non-proprietary
vehicles and/or pharmaceutical adjuvants. Compound medications
must be obtained from a participating pharmacy. You will have to
pay the full cost of the compound medications you get from a
non-participating pharmacy. If you are denied a compound
medication because you obtained it from a non-participating
pharmacy, you may file a grievance with us by following the
procedures described in the section entitled GRIEVANCE PROCEDURES.
24. Specialty drugs that must be obtained from the specialty pharmacy program, but, which are obtained from a retail pharmacy or through
the home delivery program. Unless you qualify for an exception,
these drugs are not covered by this plan (please see YOUR
PRESCRIPTION DRUG BENEFITS: PRESCRIPTION DRUG CONDITIONS OF
SERVICE). You will have to pay the full cost of the specialty
drugs you get from a retail pharmacy that you should have
obtained from the specialty pharmacy program.
If you order a specialty drug through the home delivery
program, it will be forwarded to the specialty pharmacy program
for processing and will be processed according to specialty
pharmacy program rules.
GENERAL PLAN EXCLUSIONS
No payment will be made under this plan for expenses incurred for or in connection with any of the items below. (The titles given to these exclusions and limitations are for ease of reference only; they are not meant to be an integral part of the exclusions and limitations and do not modify their meaning.) Not Medically Necessary. Services or supplies that are not medically
necessary, as defined.
Experimental or Investigative. Any experimental or investigative
procedure or medication. But, if you are denied benefits because it is
determined that the requested treatment is experimental or investigative,
you may request an independent medical review as described in REVIEW
OF DENIALS OF EXPERIMENTAL OR INVESTIGATIVE TREATMENT.
Outside the United States. Services or supplies furnished and billed by
a provider outside the United States, unless such services or supplies
are furnished in connection with urgent care or an emergency.
Crime or Nuclear Energy. Conditions that result from: (1) your
commission of or attempt to commit a felony; or (2) any release of
nuclear energy, whether or not the result of war, when government funds
are available for treatment of illness or injury arising from such release of
nuclear energy.
Uninsured. Services received before your effective date or after your
coverage ends, except as specifically stated under EXTENSION OF
BENEFITS.
Excess Amounts. Any amounts in excess of covered expense or any
benefit maximum.
Work-Related. Work-related conditions if benefits are recovered or can
be recovered, either by adjudication, settlement or otherwise, under any
workers' compensation, employer's liability law or occupational disease
law, even if you do not claim those benefits.
If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers' compensation, benefits will be provided subject to our right of recovery and reimbursement under California Labor Code Section 4903, and as described in REIMBURSEMENT FOR ACTS OF THIRD PARTIES. Government Treatment. 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 payment under this plan is expressly
required by federal or state 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. You are not required to seek any such services prior to receiving medically necessary health care services that are covered by this plan. Voluntary Payment. Services for which you are not legally obligated to
pay. Services for which no charge is made in the absence of insurance
coverage or other health plan coverage.
Not Specifically Listed. Services not specifically listed in this plan as
covered services.
Private Contracts. Services or supplies provided pursuant to a private
contract between the insured person 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.
Nicotine Use. Smoking cessation programs or treatment of nicotine or
tobacco use, if the program is not affiliated with Anthem.
Chronic Pain. Treatment of chronic pain.
REIMBURSEMENT FOR ACTS OF THIRD PARTIES
Under some circumstances, an insured person may need services under this plan for which a third party may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation. In that event, we will provide the benefits of this plan subject to the following: 1. We will automatically have a lien, to the extent of benefits provided, upon any recovery, whether by settlement, judgment or otherwise, that you receive from the third party, the third party's insurer, or the third party's guarantor. The lien will be in the amount of benefits we paid under this plan for the treatment of the illness, disease, injury or condition for which the third party is liable.  If we paid the provider other than on a capitated basis, our lien will not be more than amount we paid for those services.  If we paid the provider on a capitated basis, our lien will not be more than 80% of the usual and customary charges for those services in the geographic area in which they were given.  If you hired an attorney to gain your recovery from the third party, our lien will not be for more than one-third of the money due you under any final judgment, compromise, or settlement agreement.  If you did not hire an attorney, our lien will not be for more than one-half of the money due you under any final judgment, compromise or settlement agreement.  If a final judgment includes a special finding by a judge, jury, or arbitrator that you were partially at fault, our lien will be reduced by the same comparative fault percentage by which your recovery was reduced.  Our lien is subject to a pro rata reduction equal to your reasonable attorney's fees and costs in line with the common fund doctrine. 2. You must advise us in writing, within 60 days of filing a claim against the third party and take necessary action, furnish such information and assistance, and execute such papers as we may require to facilitate enforcement of our rights. You must not take action which may prejudice our rights or interests under your plan. Failure to give us such notice or to cooperate with us, or actions that prejudice our rights or interests will be a material breach of this plan and will result in your being personally responsible for reimbursing us. 3. We will be entitled to collect on our lien even if the amount you or anyone recovered for you (or your estate, parent or legal guardian) from or for the account of such third party as compensation for the injury, illness or condition is less than the actual loss you suffered. HOW COVERAGE BEGINS AND ENDS
HOW COVERAGE BEGINS
ELIGIBLE STATUS
1. Insured Employees. You are in an eligible status if you are a
retired employee who is actively enrolled under both Part A and Part B of Medicare. A retired employee is retired from active full-time employment, is eligible to receive health plan benefits as part of the group's pension plan and was covered under a group sponsored health plan immediately prior to retirement. 2. Family Members. The employee's spouse or domestic partner is
eligible to be enrolled as a family member, provided that the spouse or domestic partner is actively enrolled under Part A and Part B of Medicare. Spouse is the employee's spouse as recognized under state or federal law. This includes same sex spouses when legally married in a state that recognizes same-sex marriages. Domestic partner is the employee's domestic partner under a legally registered and valid domestic partnership. Spouse or domestic partner does not include any person who is covered as an employee. ELIGIBILITY DATE
For employees, you become eligible for coverage on the first day of the month coinciding with or following the date you retire. For the employee's spouse or domestic partner, you become eligible on the later of (a) the date the employee becomes eligible for coverage or (b) the date the spouse or domestic partner meets the definition of a spouse or domestic partner, respectively. ENROLLMENT
To enroll as an employee, or to enroll family members, the employee must properly file an application. An application is considered properly filed, only if it is personally signed, dated, and given to the group within 31 days from your eligibility date. We must receive this application from the group within 90 days. If any of these steps are not followed, your coverage may be denied. EFFECTIVE DATE
Your effective date of coverage is subject to the timely payment of premium on your behalf. The date you become covered is determined as follows: 1. Timely Enrollment. If you enroll for coverage before, on, or within
31 days after your eligibility date, then your coverage will begin as follows: (a) for employees, on your eligibility date; and (b) for family members, on the later of (i) the date the employee's coverage begins, or (ii) the first day of the month after the family member becomes eligible. If you become eligible before the policy takes effect, coverage begins on the effective date of the policy. 2. Late Enrollment. If you fail to enroll within 31 days after your
eligibility date, you must wait until the group's next Open Enrollment Period to enroll. 3. Disenrollment. If you voluntarily choose to disenroll from coverage
under this plan, you must wait until the group's next Open Enrollment Period to enroll. You may enroll earlier than the group's next Open Enrollment Period if you meet any of the conditions listed under SPECIAL ENROLLMENT PERIODS. Special Enrollment Periods
You may enroll without waiting for the group's next open enrollment period if you are otherwise eligible under any one of the circumstances set forth below: 1. You have met all of the following requirements: a. You were covered as an individual or dependent under either: Another employer group health plan or health insurance coverage, including coverage under a COBRA or CalCOBRA continuation; or ii. A state Medicaid plan or under a state child health insurance program (SCHIP), including the Healthy Families Program or the Access for Infants and Mothers (AIM) Program. b. You certified in writing at the time you became eligible for coverage under this plan that you were declining coverage under this plan or disenrolling because you were covered under another health plan as stated above and you were given written notice that if you choose to enroll later, you may be required to wait until the group's next open enrollment period to do so. c. Your coverage under the other health plan wherein you were covered as an individual or dependent ended as follows: If the other health plan was another employer group health plan or health insurance coverage, including coverage under a COBRA continuation, coverage ended because you lost eligibility under the other plan, your coverage under a COBRA contributions toward coverage under the other plan terminated. You must properly file an application with the group within 31 days after the date your coverage ends or the date employer contributions toward coverage under the other plan terminate. Loss of eligibility for coverage under an employer group health plan or health insurance includes loss of eligibility due to termination of employment or change in employment status, reduction in the number of hours worked, loss of dependent status under the terms of the plan, termination of the other plan, legal separation, divorce, death of the person through whom you were covered, and any loss of eligibility for coverage after a period of time that is measured by reference to any of the foregoing. ii. If the other health plan was a state Medicaid plan or a state child health insurance program (SCHIP), including the Healthy Families Program or the Access for Infants and Mothers (AIM) Program, coverage ended because you lost eligibility under the program. You must properly file an application with the group within 60 days after the date your coverage ended. 2. A court has ordered coverage be provided for a spouse, domestic partner under your employee health plan and an application is filed within 31 days from the date the court order is issued. 3. We do not have a written statement from the group stating that prior to declining coverage or disenrolling, you received and signed acknowledgment of a written notice specifying that if you do not enroll for coverage within 31 days after your eligibility date, or if you disenroll, and later file an enrollment application, your coverage may not begin until the first day of the month following the end of the group's next open enrollment period. 4. You have a change in family status through marriage or establishment of a domestic partnership. You may also enroll a new spouse or domestic partner at that time. You must enroll within 31 days of the date of the marriage or establishment of the domestic partnership. 5. You meet or exceed a lifetime limit on all benefits under another health plan. Application must be made within 31 days of the date a claim or a portion of a claim is denied due to your meeting or exceeding the lifetime limit on all benefits under the other plan. 6. You become eligible for assistance, with respect to the cost of coverage under the employer's group plan, under a state Medicaid or SCHIP health plan, including any waiver or demonstration project conducted under or in relation to these plans. You must properly file an application with the group within 60 days after the date you are determined to be eligible for this assistance. Effective date of coverage. For enrollments during a special
enrollment period as described above, coverage will be effective on the
first day of the month following the date you file the enrollment
application.
OPEN ENROLLMENT PERIOD
The group has an open enrollment period once each year, during the month of October. During that time, an individual who meets the eligibility requirements as an employee under this plan may enroll in this plan. The employee may also enroll an eligible spouse or domestic partner at that time. For anyone so enrolling, coverage under this plan will begin on the first day of the month following the end of the Open Enrollment Period. HOW COVERAGE ENDS
Your coverage ends, without notice from us, as provided below: 1. If the policy terminates, your coverage ends at the same time. The policy may be cancelled or changed without notice to you. 2. If the group no longer provides coverage for the class of insured persons to which you belong, your coverage ends on the effective date of that change. If this policy is amended to delete coverage for family members, a family member's coverage ends on the effective date of that change. 3. Coverage for family members ends when the employee's coverage 4. Coverage ends at the end of the period for which premium has been paid to us on your behalf when the required premium for the next period is not paid. 5. If you voluntarily cancel coverage at any time, coverage ends on the premium due date coinciding with or following the date of voluntary cancellation, as provided by written notice to us. 6. If you no longer meet the requirements set forth in the "Eligible Status" provision of HOW COVERAGE BEGINS, your coverage ends as of the premium due date coinciding with or following the date you cease to meet such requirements. Note: If a marriage or domestic partnership terminates, the insured
person must give or send to the group written notice of the termination.
Coverage for a former spouse or domestic partner, if any, ends
according to the "Eligible Status" provisions. If Anthem Blue Cross Life
and Health Insurance suffers a loss because of the insured person failing
to notify the group of the termination of their marriage or domestic
partnership, Anthem Blue Cross Life and Health Insurance may seek
recovery from the insured person for any actual loss resulting thereby.
Failure to provide written notice to the group will not delay or prevent
termination of the marriage or domestic partnership. If the insured person
notifies the group in writing to cancel coverage for a former spouse or
domestic partner, if any, immediately upon termination of the insured
person's marriage or domestic partnership, such notice will be
considered compliance with the requirements of this provision.
You may be entitled to continued benefits under terms which are specified elsewhere under CONTINUATION OF COVERAGE and EXTENSION OF BENEFITS. Unfair Termination of Coverage. If you believe that your coverage has
been or will be improperly terminated, you may request a review of the
matter by the California Department of Insurance (CDI). You may
contact the CDI using the address and telephone numbers listed in the
COMPLAINT NOTICE. You must make your request for review with the CDI
within 180 days from the date you receive notice that your coverage will
end, or the date your coverage is actually cancelled, whichever is later,
but you should make your request as soon as possible after you receive
notice that your coverage will end. This 180 day timeframe will not apply
if, due to substantial health reasons or other incapacity, you are unable
to understand the significance of the cancellation notice and act upon it.
If you make your request for review within 30 days after you receive
notice that your coverage will end, or your coverage is still in effect when
you make your request, we will continue to provide coverage to you
under the terms of this plan until a final determination of your request for
review has been made by the CDI (this does not apply if your coverage
is cancelled for non-payment of premium). If your coverage is
maintained in force pending outcome of the review, premium must still be
paid to us on your behalf.
CONTINUATION OF COVERAGE
Most employers who employ 20 or more people on a typical business day are subject to The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). If the employer who provides coverage under the policy is subject to the federal law which governs this provision (Title X of P. L. 99-272), you may be entitled to a period of continuation of coverage. Check with your employer for details. DEFINITIONS
The meanings of key terms used in this section are shown below. Whenever any of the terms shown below appear in these provisions, the first letter of each word will be capitalized. When you see these capitalized words, you should refer to this "Definitions" provision. Initial Enrollment Period is the period of time following the original
Qualifying Event, as indicated in the "Terms of COBRA Continuation"
provisions below.
Qualified Beneficiary means a person enrolled for this COBRA
continuation coverage who, on the day before the Qualifying Event, was
covered under this policy as either an employee or enrolled spouse.
Qualified Beneficiary does not include any person who was not enrolled
during the Initial Enrollment Period, including a spouse acquired during
the COBRA continuation period. It does not include domestic partners if
they are eligible under HOW COVERAGE BEGINS AND ENDS.
Qualifying Event means any one of the following circumstances which
would otherwise result in the termination of your coverage under the
policy. The events will be referred to throughout this section by number.
1. For Employees and the Spouse:
a. The employee's termination of employment, for any reason other than gross misconduct; or b. Loss of coverage under an employer's health plan due to a reduction in the employee's work hours. 2. For Retired Employees and the Spouse. Cancellation or a
substantial reduction of retiree benefits under the plan due to the group's filing for Chapter 11 bankruptcy, provided that: a. The policy expressly includes coverage for retirees; and b. Such cancellation or reduction of benefits occurs within one year before or after the group's filing for bankruptcy. 3. For the Spouse:
a. The death of the employee; or b. The spouse's divorce or legal separation from the employee.
ELIGIBILITY FOR COBRA CONTINUATION
An insured employee or insured family member may choose to continue coverage under the policy if his or her coverage would otherwise end due to a Qualifying Event. TERMS OF COBRA CONTINUATION
Notice. The group or its administrator (we are not the administrator) will
notify either the employee or spouse of the right to continue coverage
under COBRA, as provided below:
1. For Qualifying Events 1 or 2, the group or its administrator will notify the employee of the right to continue coverage. 2. For Qualifying Event 3(a), the spouse will be notified of the COBRA continuation right. 3. You must inform the group within 60 days of Qualifying Event 3(b) if you wish to continue coverage. The group in turn will promptly give you official notice of the COBRA continuation right. If you choose to continue coverage you must notify the group within 60 days of the date you receive notice of your COBRA continuation right. The COBRA continuation coverage may be chosen for both family members, or for the employee only, or for the spouse only. If you fail to elect the COBRA continuation during the Initial Enrollment Period, you may not elect the COBRA continuation at a later date. Notice of continued coverage, along with the initial premium, must be delivered to us by the group within 45 days after you elect COBRA continuation coverage. Additional Family Members. A spouse acquired during the COBRA
continuation period is eligible to be enrolled, provided that the spouse
meets the eligibility requirements specified in HOW COVERAGE BEGINS.
The standard enrollment provisions of the policy apply to enrollees
during the COBRA continuation period.
Cost of Coverage. The group may require that you pay the entire cost
of your COBRA continuation coverage. This cost, called the "premium",
must be remitted to the group each month during the COBRA
continuation period. We must receive payment of the premium each
month from the group in order to maintain the coverage in force.
Besides applying to the employee, the employee's rate also applies to a spouse whose COBRA continuation began due to divorce, separation or death of the employee.
Subsequent Qualifying Events. Once covered under the COBRA
continuation, it's possible for a second Qualifying Event to occur. If that
happens, an insured person, who is a Qualified Beneficiary, may be
entitled to an extended COBRA continuation period. This period will in
no event continue beyond 36 months from the date of the first qualifying
event.
For example, a spouse may have been originally eligible for this COBRA continuation due to termination of the employee's employment, and enrolled for this COBRA continuation as a Qualified Beneficiary. If, during the COBRA continuation period, the spouse becomes divorced or legally separated from the employee, the spouse is eligible for an extended continuation period which would end no later than 36 months from the date of the original Qualifying Event (the termination of employment). When COBRA Continuation Coverage Begins. When COBRA
continuation coverage is elected during the Initial Enrollment Period and
the premium is paid, coverage is reinstated back to the date of the
original Qualifying Event, so that no break in coverage occurs.
For a spouse properly enrolled during the COBRA continuation, coverage begins according to the enrollment provisions of the policy. When the COBRA Continuation Ends. This COBRA continuation will
end on the earliest of:
1. The end of 18 months from the Qualifying Event, if the Qualifying Event was termination of employment or reduction in work hours;* 2. The end of 36 months from the Qualifying Event, if the Qualifying Event was the death of the employee, divorce or legal separation;* 3. The date the policy terminates; 4. The end of the period for which premiums are last paid; 5. The date, following the election of COBRA, the insured person first becomes covered under any other group health plan, unless the other group health plan contains an exclusion or limitation relating to a pre-existing condition of the insured person, in which case this COBRA continuation will end at the end of the period for which the pre-existing condition exclusion or limitation applied. *For an insured person whose COBRA continuation coverage began under a prior plan, this term will be dated from the time of the Qualifying Event under that prior plan. Subject to the policy remaining in effect, a retired employee whose COBRA continuation coverage began due to Qualifying Event 2 may be covered for the remainder of his or her life; that person's enrolled spouse may continue coverage for 36 months after the employee's death. But coverage could terminate prior to such time for either the employee or spouse in accordance with any of the items above. Other Coverage Options Besides COBRA Continuation Coverage.
Instead of enrolling in COBRA continuation coverage, there may be other
coverage options for you and your family through the Health Insurance
Marketplace, Medicaid, or other group health plan coverage options
(such as a spouse's plan) through the conditions listed under the
SPECIAL ENROLLMENT PERIODS provision. Some of these options may
cost less than COBRA continuation coverage. You can learn more about
many of these options at
EXTENSION OF CONTINUATION DURING TOTAL DISABILITY
If at any time during the first 60 days of the COBRA continuation, a Qualified Beneficiary is determined to be disabled for Social Security purposes, all covered insured persons may be entitled to up to 29 months of continuation coverage after the Qualifying Event. Eligibility for Extension. To continue coverage for up to 29 months
from the date of the original Qualifying Event, the disabled insured
person must:
1. Satisfy the legal requirements for being totally and permanently disabled under the Social Security Act; and 2. Be determined and certified to be so disabled by the Social Security Notice. The insured person must furnish the group with proof of the
Social Security Administration's determination of disability during the first
18 months of the COBRA continuation period and no later than 60 days
after the later of the following events:
1. The date of the Social Security Administration's determination of the 2. The date on which the original Qualifying Event occurs; 3. The date on which the Qualified Beneficiary loses coverage; or 4. The date on which the Qualified Beneficiary is informed of the obligation to provide the disability notice.
Cost of Coverage. For the 19th through 29th months that the total
disability continues, the group must remit the cost for the extended
continuation coverage to us. This cost (called the "premium") shall be
subject to the following conditions:
1. If the disabled insured person continues coverage during this extension, this rate shall be 150% of the applicable rate for the
length of time the disabled insured person remains covered,
depending upon the number of covered dependents. If the disabled
insured person does not continue coverage during this extension,
this charge shall remain at 102% of the applicable rate.
2. The cost for extended continuation coverage must be remitted to us by the group each month during the period of extended continuation coverage. We must receive timely payment of the premium each month from the group in order to maintain the extended continuation coverage in force. 3. The group may require that you pay the entire cost of the extended continuation coverage. If a second Qualifying Event occurs during this extended continuation,
the total COBRA continuation may continue for up to 36 months from the
date of the first Qualifying Event. The premium rate shall then be 150%
of the applicable rate for the 19th through 36th months if the disabled
insured person remains covered. The charge will be 102% of the
applicable rate for any periods of time the disabled insured person is not
covered following the 18th month.
When The Extension Ends. This extension will end at the earlier of:
1. The end of the month following a period of 30 days after the Social Security Administration's final determination that you are no longer totally disabled; 2. The end of 29 months from the Qualifying Event; 3. The date the policy terminates; 4. The end of the period for which premiums are last paid; 5. The date, following the election of COBRA, the insured person first becomes covered under any other group health plan, unless the other group health plan contains an exclusion or limitation relating to a pre-existing condition of the insured person, in which case this COBRA extension will end at the end of the period for which the pre-existing condition exclusion or limitation applied. You must inform the group within 30 days of a final determination by the Social Security Administration that you are no longer totally disabled. EXTENSION OF BENEFITS
If you are a totally disabled employee or a totally disabled family member and under the treatment of a physician on the date of discontinuance of the policy, your benefits may be continued for treatment of the totally disabling condition. This extension of benefits is not available if you become covered under another group health plan that provides coverage without limitation for your disabling condition. Extension of benefits is subject to the following conditions: 1. If you are confined as an inpatient in a hospital or skilled nursing facility, you are considered totally disabled as long as the inpatient stay is medically necessary, and no written certification of the total disability is required. If you are discharged from the hospital or skilled nursing facility, you may continue your total disability benefits by submitting written certification by your physician of the total disability within 90 days of the date of your discharge. Thereafter, we must receive proof of your continuing total disability at least once every 90 days while benefits are extended. 2. If you are not confined as an inpatient but wish to apply for total disability benefits, you must do so by submitting written certification by your physician of the total disability. We must receive this certification within 90 days of the date coverage ends under this plan. At least once every 90 days while benefits are extended, we must receive proof that your total disability is continuing. 3. Your extension of benefits will end when any one of the following circumstances occurs: a. You are no longer totally disabled. b. The maximum benefits available to you under this plan are paid. c. You become covered under another group health plan that provides benefits without limitation for your disabling condition. d. A period of up to 12 months has passed since your extension GENERAL PROVISIONS
Providing of Care. We are not responsible for providing any type of
pharmacy care, nor are we responsible for the quality of any such care
received.

Independent Contractors. Our relationship with providers is that of an
independent contractor. Pharmacies, and other community agencies are
not our agents nor are we, or any of our employees, an employee or
agent of any provider of any type.
Non-Regulation of Providers. The benefits of this plan do not regulate
the amounts charged by providers of pharmacy services, except to the
extent that rates for covered services are regulated with participating
pharmacies.
Terms of Coverage
1. In order for you to be entitled to benefits under the policy, both the policy and your coverage under the policy must be in effect on the date the expense giving rise to a claim for benefits is incurred. 2. The benefits to which you may be entitled will depend on the terms of coverage in effect on the date the expense giving rise to a claim for benefits is incurred. An expense is incurred on the date you receive the service or supply for which the charge is made. 3. The policy is subject to amendment, modification or termination according to the provisions of the policy without your consent or concurrence. Nondiscrimination. No person who is eligible to enroll will be refused
enrollment based on health status, health care needs, genetic
information, previous medical information, disability, sexual orientation or
identity, gender, or age.
Protection of Coverage. We do not have the right to cancel your
coverage under this plan while: (1) this plan is in effect; (2) you are
eligible; and (3) your premiums are paid according to the terms of the
policy.
Free Choice of Provider. You may choose any pharmacy facility which
provides care covered under this plan, and is properly licensed according
to appropriate state and local laws. However, your choice may affect the
benefits payable according to this plan.
Availability of Care. If there is an epidemic or public disaster and you
cannot obtain care for covered services, we refund the unearned part of
the premium charge paid for you. A written request for that refund and
satisfactory proof of the need for care must be sent to us within 31 days.
This payment fulfills our obligation under this plan.
Medical Necessity. The benefits of this plan are provided only for
services which are medically necessary. The services must be ordered
by the attending physician for the direct care and treatment of a covered
condition. They must be standard medical practice where received for
the condition being treated and must be legal in the United States. The process used to authorize or deny health care services under this plan is available to you upon request. Expense in Excess of Benefits. We are not liable for any expense you
incur in excess of the benefits of this plan.
Benefits Not Transferable. Only insured persons are entitled to receive
benefits under this plan. The right to benefits cannot be transferred.
Notice of Claim. You, or someone on your behalf, must give us written
notice of a claim within 20 days after you incur covered expense under
this plan, or as soon as reasonably possible thereafter.
Claim Forms. After we receive a written notice of claim, we will give you
any forms you need to file proof of loss. If we do not give you these
forms within 15 days after you have filed your notice of claim, you will not
have to use these forms, and you may file proof of loss by sending us
written proof of the occurrence giving rise to the claim. Such written
proof must include the extent and character of the loss.
Proof of Loss. You or the provider of service must send us properly
and fully completed claim forms within 90 days of the date you receive
the service or supply for which a claim is made. If it is not reasonably
possible to submit the claim within that time frame, an extension of up to
12 months will be allowed. Except in the absence of legal capacity, we
are not liable for the benefits of the plan if you do not file claims within
the required time period. We will not be liable for benefits if we do not
receive written proof of loss on time.
Services received and charges for the services must be itemized, and clearly and accurately described. Claim forms must be used; canceled checks or receipts are not acceptable. Timely Payment of Claims. Any benefits due under this plan shall be
due once we have received proper, written proof of loss, together with
such reasonably necessary additional information we may require to
determine our obligation.
Payment to Providers. We will pay the benefits of this plan directly to
participating providers. Also, we will pay providers of service directly
when you assign benefits in writing. If another party pays for your
medical care and you assign benefits in writing, we will pay the benefits
of this plan to that party. These payments will fulfill our obligation to you
for those covered services.
Right of Recovery. Whenever payment has been made in error, we will
have the right to recover such payment from you or, if applicable, the
provider, in accordance with applicable laws and regulations. In the
event we recover a payment made in error from the provider, except in cases of fraud or misrepresentation on the part of the provider, we will only recover such payment from the provider within 365 days of the date we made the payment on a claim submitted by the provider. We reserve the right to deduct or offset any amounts paid in error from any pending or future claim. Under certain circumstances, if we pay your healthcare provider amounts that are your responsibility, such as deductibles, co-payments or co-insurance, we may collect such amounts directly from you. You agree that we have the right to recover such amounts from you. We have oversight responsibility for compliance with provider and vendor and subcontractor contracts. We may enter into a settlement or compromise regarding enforcement of these contracts and may retain any recoveries made from a provider, vendor, or subcontractor resulting from these audits if the return of the overpayment is not feasible. We have established recovery policies to determine which recoveries are to be pursued, when to incur costs and expenses, and whether to settle or compromise recovery amounts. We will not pursue recoveries for overpayments if the cost of collection exceeds the overpayment amount. We may not provide you with notice of overpayments made by us or you if the recovery method makes providing such notice administratively burdensome. Plan Administrator - COBRA and ERISA. In no event will we be plan
administrator for the purposes of compliance with the Consolidated
Omnibus Budget Reconciliation Act (COBRA) or the Employee
Retirement Income Security Act (ERISA). The term "plan administrator"
refers either to the group or to a person or entity other than us, engaged
by the group to perform or assist in performing administrative tasks in
connection with the group's health plan. The group is responsible for
satisfaction of notice, disclosure and other obligations of administrators
under ERISA. In providing notices and otherwise performing under the
CONTINUATION OF COVERAGE section of this booklet, the group is fulfilling
statutory obligations imposed on it by federal law and, where applicable,
acting as your agent.
Workers' Compensation Insurance. The policy does not affect any
requirement for coverage by workers' compensation insurance. It also
does not replace that insurance.
Conformity with Laws. Any provision of the policy which, on its
effective date, is in conflict with the laws of the governing jurisdiction, is
hereby amended to conform to the minimum requirements of such laws.
BINDING ARBITRATION
NOTE: If you wish to appeal a decision made by Medicare and not by
us, you must initiate the appeal process by contacting your local Social
Security Administration office.
DEFINITIONS
The meanings of key terms used in this certificate are shown below. Whenever any of the key terms shown below appear, it will appear in italicized letters. When any of the terms below are italicized in your certificate, you should refer to this section. Brand name prescription drug (brand name drug) is a prescription
drug that has been patented and is only produced by one manufacturer.
Creditable coverage is any individual or group plan that provides
medical, hospital and surgical coverage, including continuation or
conversion coverage, coverage under Medicare or Medicaid, TRICARE,
the Federal Employees Health Benefits Program, programs of the Indian
Health Service or of a tribal organization, a state health benefits risk
pool, coverage through the Peace Corps, the State Children's Health
Insurance Program, or a public health plan established or maintained by
a state, the United States government, or a foreign country. Creditable
coverage does not include accident only, credit, coverage for on-site
medical clinics, disability income, coverage only for a specified disease
or condition, hospital indemnity or other fixed indemnity insurance,
Medicare supplement, long-term care insurance, dental, vision, workers'
compensation insurance, automobile insurance, no-fault insurance, or
any medical coverage designed to supplement other private or
governmental plans. Creditable coverage is used to set up eligibility
rules for children who cannot get a self-sustaining job due to a physical
or mental condition. In addition, eligible children were covered under
one of the above types of health coverage on his or her own and not as a
dependent child.
If your prior coverage was through an employer, you will receive credit for that coverage if it ended because your employment ended, the availability of medical coverage offered through employment or sponsored by the employer terminated, or the employer's contribution toward medical coverage terminated, and any lapse between the date that coverage ended and the date you become eligible under this plan is no more than 180 days (not including any waiting period imposed under this plan by the employer). If your prior coverage was not through an employer, you will receive credit for that coverage if any lapse between the date that coverage ended and the date you become eligible under this plan is no more than 63 days (not including any waiting period imposed under this plan by the employer). Compound Medication is a mixture of prescription drugs and other
ingredients, wherein one or more ingredients are FDA-approved, a
prescription is required to dispense, and the compound medication is not
essentially the same as an FDA-approved product from a drug
manufacturer.
Covered expense is the expense you incur for a covered service or
supply, but not more than the maximum amounts described in YOUR
PRESCRIPTION DRUG BENEFITS: PRESCRIPTION DRUG COVERED EXPENSE.
Expense is incurred on the date you receive the service or supply.
Domestic partner meets the plan's eligibility requirements for domestic
partners as outlined under HOW COVERAGE BEGINS AND ENDS: HOW
COVERAGE BEGINS.
Drug (prescription drug) means a prescribed drug approved by the
Food and Drug Administration for general use by the public. For the
purposes of this plan, insulin will be considered a prescription drug.
Effective date is the date your coverage begins under this plan.
Experimental procedures are those that are mainly limited to laboratory
and/or animal research.
Family member means the insured employee's enrolled spouse or
domestic partner.
Formulary drug is a drug listed on the prescription drug formulary.
Generic prescription drug (generic drug) is a pharmaceutical
equivalent of one or more brand name drugs and must be approved by
the Food and Drug Administration as meeting the same standards of
safety, purity, strength, and effectiveness as the brand name drug.
Group refers to the business entity to which we have issued this policy.
The name of the group is SAN BERNARDINO MUNICIPAL WATER
DEPARTMENT.
Hospital is a facility which provides diagnosis, treatment and care of
persons who need acute inpatient hospital care under the supervision of
physicians. It must be licensed as a general acute care hospital
according to state and local laws. It must also be registered as a general
hospital by the American Hospital Association and meet accreditation
standards of the Joint Commission on Accreditation of Health Care
Organizations.
For the limited purpose of inpatient care for the acute phase of a mental or nervous disorder, or substance abuse, "hospital" also includes psychiatric health facilities. Infertility is (1) the presence of a condition recognized by a physician as
a cause of infertility, or (2) the inability to conceive a pregnancy to a live
birth after a year or more of regular sexual relations without
contraception.
Insured employee (employee) is the primary insured; that is, the
person who is allowed to enroll under this plan for himself or herself and
his or her eligible family members.
Insured person is the retiree or covered spouse or domestic partner of
the retiree. An insured person may enroll under only one health plan
provided by Anthem Blue Cross Life and Health, or any of its affiliates,
which is sponsored by the group.
Investigative procedures or medications are those that have progressed
to limited use on humans, but which are not widely accepted as proven
and effective within the organized medical community.
Medically necessary services, procedures, equipment or supplies are
those which are:
1. Appropriate and necessary for the diagnosis or treatment of the medical condition; 2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient's il ness, injury or disease; 3. Provided for the diagnosis or direct care and treatment of the medical condition; 4. Within standards of good medical practice within the organized medical community; 5. Not primarily for your convenience, or the convenience of your physician or another provider; 6. Not more costly than an equivalent service or sequence of services that is medically appropriate and is likely to produce equivalent therapeutic or diagnostic results in regard to the diagnosis or treatment of the patient's illness, injury, or condition; and 7. The most appropriate procedure, supply, equipment or service which can safely be provided. NOTE: We will accept Medicare's determination of medical necessity.

Multi-source brand name drugs are drugs with at least one generic
substitute.
Medicare is the name commonly used to describe "Health Insurance
Benefits for the Aged and Disabled" provided under Public Law 89-97
and its amendments.
Mental or nervous disorders, including substance abuse, for the
purposes of this plan, are conditions that are listed in the most current
edition of the Diagnostic and Statistical Manual (DSM) of Mental
Disorders. Mental or nervous disorders include severe mental disorders
as defined in this plan (see definition of "severe mental disorders").
Non-participating pharmacy is a pharmacy which does not have a
contract in effect with the pharmacy benefits manager at the time
services are rendered. In most cases, you will be responsible for a
larger portion of your pharmaceutical bill when you go to a non-
participating pharmacy.
Participating pharmacy is a pharmacy which has a Participating
Pharmacy Agreement in effect with the pharmacy benefit manager at
the time services are rendered. Call your local pharmacy to determine
whether it is a participating pharmacy or call the toll-free customer
service telephone number.
Pharmacy means a licensed retail pharmacy.
Pharmacy and Therapeutics Process is a process in which health care
professionals including nurses, pharmacists, and physicians determine
the clinical appropriateness of drugs and promote access to quality
medications. The process also reviews drugs to determine the most cost
effective use of benefits and advise on programs to help improve care.
Our programs include, but are not limited to, drug utilization programs,
prior authorization criteria, therapeutic conversion programs, cross-
branded initiatives, and drug profiling initiatives.
Pharmacy Benefits Manager (PBM) is the entity with which Anthem
has contracted with to administer its prescription drug benefits. The PBM
is an independent contractor and not affiliated with Anthem.
Physician means a licensed practitioner of the healing arts acting within
the scope of their license.
Plan is the set of benefits described in this booklet and in the
amendments to this booklet (if any). This plan is subject to the terms and
conditions of the policy we have issued to the group. If changes are
made to the plan, an amendment or revised booklet will be issued to the
group for distribution to each employee affected by the change. (The
word "plan" here does not mean the same as "plan" as used in ERISA.)

Policy is the Group Policy we have issued to the group.
Pre-existing condition means an illness, injury or condition which
existed during the six-month period immediately prior to either (a) your
effective date or (b) the first day of any waiting period required by the
group, whichever is earlier. A condition is considered to have existed
when you: (1) sought or received medical advice for that condition; (2)
received medical care or treatment for that condition; or (3) received
medical supplies, drugs or medicines for that condition.
Prescription drug covered expense is the expense you incur for a
covered prescription drug, but not more than the prescription drug
maximum allowed amount. Expense is incurred on the date you receive
the service or supply.
Prescription drug maximum allowed amount is the maximum amount
allowed for any drug. The amount is determined by using prescription
drug cost information provided to us by the pharmacy benefits manager.
The amount is subject to change. You may determine the prescription
drug maximum allowed amount of a particular drug by calling 1-800-700-
2541 (or TTY/TDD 1-800-905-9821).
Prescription drug formulary (formulary) is a list which we have
developed of outpatient prescription drugs which may be cost-effective,
therapeutic choices. Any participating pharmacy can assist you in
purchasing drugs listed on the formulary. You may also get information
about covered formulary drugs by calling 1-800-700-2541 or going to our
internet website anthem.com/ca.
Prescription means a written order or refill notice issued by a licensed
prescriber.
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 Pharmacy and
Therapeutics Process. 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
will you need to get written prior authorization (see PRESCRIPTION DRUG
FORMULARY: PRIOR AUTHORIZATION above) to get that 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 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 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 or multi-source brand name drugs.  Tier 4 Drugs are those that have the higher copayments than Tier 3
Prescription drug maximum allowed amount is the maximum amount
allowed for any drug. The amount is determined by using prescription
drug cost information provided to us by the pharmacy benefits manager.
The amount is subject to change. You may determine the prescription
drug maximum allowed amount of a particular drug by calling 1-800-700-
2541 (or TTY/TDD 1-800-905-9821).
Prior plan is a plan sponsored by the group which was replaced by this
plan within 60 days. You are considered covered under the prior plan if
you: (1) were covered under the prior plan on the date that plan
terminated; (2) properly enrolled for coverage within 31 days of this
plan's Effective Date; and (3) had coverage terminate solely due to the
prior plan's termination.
Psychiatric health facility is an acute 24-hour facility as defined in
California Health and Safety Code 1250.2. It must be:
1. Licensed by the California Department of Health Services; 2. Qualified to provide short-term inpatient treatment according to the California Insurance Code; 3. Accredited by the Joint Commission on Accreditation of Health Care Organizations; and 4. Staffed by an organized medical or professional staff which includes a physician as medical director. Retired employee is a former full-time employee who meets the
eligibility requirements described in the "Eligible Status" provision in HOW
COVERAGE BEGINS AND ENDS.
Severe mental disorders include the following psychiatric diagnoses
specified in California Insurance Code section 10144.5: schizophrenia,
schizoaffective disorder, bipolar disorder, major depression, panic
disorder, obsessive-compulsive disorder, pervasive developmental
disorder or autism, anorexia, and bulimia.
"Severe mental disorders" also includes serious emotional disturbances of a child as indicated by the presence of one or more mental disorders as identified in the Diagnostic and Statistical Manual (DSM) of Mental Disorders, other than primary substance abuse or developmental disorder, resulting in behavior inappropriate to the child's age according to expected developmental norms. The child must also meet one or more of the following criteria: 1. As a result of the mental disorder, the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community and is at risk of being removed from the home or has already been removed from the home or the mental disorder has been present for more than six months or is likely to continue for more than one year without treatment. 2. The child is psychotic, suicidal, or potentially violent. 3. The child meets special education eligibility requirements under California law (Government Code Section 7570). Single source brand name drugs are drugs with no generic substitute.
Skilled nursing facility is an institution that provides continuous skilled
nursing services. It must be licensed according to state and local laws
and be recognized as a skilled nursing facility under Medicare.
Specialty drugs are typically 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.
Certain specified specialty drugs may require special handling, such as
temperature controlled packaging and overnight delivery, and therefore,
certain specified specialty drugs will be required to be obtained through
the specialty pharmacy program, unless you qualify for an exception.
Spouse meets the plan's eligibility requirements for spouses as outlined
under HOW COVERAGE BEGINS AND ENDS.
Stay is inpatient confinement which begins when you are admitted to a
facility and ends when you are discharged from that facility.
Totally disabled employees are employees who, because of illness or
injury, are unable to work for income in any job for which they are
qualified or for which they become qualified by training or experience,
and who are in fact unemployed.
Totally disabled family members are family members who are unable
to perform all activities usual for persons of that age.

Urgent care is the services received for a sudden, serious, or
unexpected illness, injury or condition, other than one which is life
threatening, which requires immediate care for the relief of severe pain
or diagnosis and treatment of such condition.
We (us, our) refers to Anthem Blue Cross Life and Health Insurance
Company or Anthem Blue Cross (an affiliate of Anthem Blue Cross Life
and Health).
Year or calendar year is a 12 month period starting January 1 at 12:01
a.m. Pacific Standard Time.
You (your) refers to the insured employee and insured family members
who are enrolled for benefits under this plan.
INDEPENDENT MEDICAL REVIEW OF DENIALS OF
EXPERIMENTAL OR INVESTIGATIVE TREATMENT
If coverage for a proposed treatment is denied because we determine that the treatment is experimental or investigative, you may ask that the denial be reviewed by an external independent medical review organization contracting with the California Department of Insurance ("CDI"). Your request for this review may be submitted to the CDI. You pay no application or processing fees of any kind for this review. You have the right to provide information in support of your request for review. A decision not to participate in this review process may cause you to forfeit any statutory right to pursue legal action against us regarding the disputed health care service. We will send you an application form and an addressed envelope for you to use to request this review with any grievance disposition letter denying coverage for this reason. You may also request an application form by calling us at the telephone number listed on your identification card or write to us at Anthem Blue Cross Life and Health Insurance Company, P.O. Box 4310, Woodland Hills, CA 91365-4310. To qualify for this review, all of the following conditions must be met:  You have a life-threatening or seriously debilitating condition, described as follows:  A life-threatening condition is a condition or disease where the likelihood of death is high unless the course of the disease is interrupted or a condition or disease with a potentially fatal outcome where the end point of clinical intervention is the patient's survival.  A seriously debilitating condition is a disease or condition that causes major, irreversible morbidity.  Your physician must certify that either (a) standard treatment has not been effective in improving your condition, (b) standard treatment is not medically appropriate, or (c) there is no more beneficial standard treatment covered by this plan than the proposed treatment.  The proposed treatment must be requested by you or by a licensed board certified or board eligible physician qualified to treat your condition. The treatment requested must be likely to be more beneficial for you than standard treatments based on two documents of scientific and medical evidence from the following sources: a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized standards; b) Medical literature meeting the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database of Health Services Technology Assessment Research (HSTAR); c) Medical journals recognized by the Secretary of Health and Human Services, under Section 1861(t)(2) of the Social Security Act; d) Either of the following: (i) The American Hospital Formulary Service's Drug Information, or (i ) the American Dental Association Accepted Dental Therapeutics; e) Any of the following references, if recognized by the federal Centers for Medicare and Medicaid Services as part of an anticancer chemotherapeutic regimen: (i) the Elsevier Gold Standard's Compendium, or (iii) the Thomson Micromedex DrugDex; f) Findings, studies or research conducted by or under the auspices of federal governmental agencies and nationally recognized federal research institutes, including the Federal Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Centers for Medicare and Medicaid Services, Congressional Office of Technology Assessment, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services; and g) Peer reviewed abstracts accepted for presentation at major medical association meetings. In all cases, the certification must include a statement of the evidence relied upon. You are not required to go through our grievance process for more than 30 days. If your grievance needs expedited review, you are not required to go through our grievance process for more than three days. You must request this review within six months of the date you receive a denial notice from us in response to your grievance, or from the end of the 30 day or three day grievance period, whichever applies. This application deadline may be extended by the CDI for good cause. Within three business days of receiving notice from the CDI of your request for review we will send the reviewing panel all relevant medical records and documents in our possession, as well as any additional information submitted by you or your physician. Any newly developed or discovered relevant medical records identified by us or by a qualified physician after the initial documents are sent will be immediately forwarded to the reviewing panel. The external independent review organization will complete its review and render its opinion within 30 days of its receipt of request for review (or within seven days if your physician determines that the proposed treatment would be significantly less effective if not provided promptly). This timeframe may be extended by up to three days for any delay in receiving necessary records. INDEPENDENT MEDICAL REVIEW OF GRIEVANCES
INVOLVING A DISPUTED HEALTH CARE SERVICE
You may request an independent medical review ("IMR") of disputed health care services from the California Department of Insurance ("CDI") if you believe that we have improperly denied, modified, or delayed health care services. A "disputed health care service" is any health care service eligible for coverage and payment under your plan that has been denied, modified, or delayed by us, in whole or in part because the service is not medically necessary. The IMR process is in addition to any other procedures or remedies that may be available to you. You pay no application or processing fees of any kind for IMR. You have the right to provide information in support of the request for IMR. We must provide you with an IMR application form and an addressed envelope for you to use to request IMR with any grievance disposition letter that denies, modifies, or delays health care services. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against us regarding the disputed health care service. Eligibility: The CDI will review your application for IMR to confirm that: 1. (a) Your provider has recommended a health care service as medically necessary, or (b) You have received urgent care or emergency services that a provider determined was medically necessary, or (c) You have been seen by a provider for the diagnosis or treatment of the medical condition for which you seek independent review; 2. The disputed health care service has been denied, modified, or delayed by us, based in whole or in part on a decision that the health care service is not medically necessary; and 3. You have filed a grievance with us and the disputed decision is upheld or the grievance remains unresolved after 30 days. If your grievance requires expedited review you need not participate in our grievance process for more than three days. The CDI may waive the requirement that you follow our grievance process in extraordinary and compelling cases. You must apply for IMR within six months of the date you receive a denial notice from us in response to your grievance or from the end of the 30 day or three day grievance period, whichever applies. This application deadline may be extended by the CDI for good cause. If your case is eligible for IMR, the dispute will be submitted to a medical specialist or specialists who will make an independent determination of whether or not the care is medically necessary. You will receive a copy of the assessment made in your case. If the IMR determines the service is medically necessary, we will provide benefits for the health care service. For non-urgent cases, the IMR organization designated by the CDI must provide its determination within 30 days of receipt of your application and supporting documents. For urgent cases involving an imminent and serious threat to your health, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of your health, the IMR organization must provide its determination within 3 days. For more information regarding the IMR process, or to request an application form, please call us at the customer service telephone number listed on your ID card. FOR YOUR INFORMATION
Information specific to your benefits and claims history are available by
calling the 800 number on your identification card. Anthem Blue Cross
Life and Health is an affiliate of Anthem Blue Cross. You may use
Anthem Blue Cross' web site to access benefit information, claims
payment status, benefit maximum status, participating providers or to
order an ID card. Simply log on to www.anthem.com/ca, select
"Member", and click the "Register" button on your first visit to establish a
User ID and Password to access the personalized and secure
MemberAccess Web site. Once registered, simply click the "Login"
button and enter your User ID and Password to access the
MemberAccess Web site. Our privacy statement can also be viewed on
our website.

Source: https://www.ci.san-bernardino.ca.us/civicax/filebank/blobdload.aspx?BlobID=20348