LAPRA 2018/19 Benefits Guide for Active Members

8 Pre-service Review Requirements Pre-service review establishes in advance the medical necessity of certain care and services covered under the Anthem Blue Cross HMO or PPO medical plans. Not all services which require pre-service review are listed here. For a complete list of services requiring pre-service review, contact Anthem Blue Cross at the telephone number listed on the back of your ID card. Pre-service review is required under both the HMO and PPO medical plans for facility-based care for the treatment of mental or nervous disorders, severe mental disorders, and substance abuse. Anthem Blue Cross PPO Pre-service review is also required for the following services under the Anthem Blue Cross PPO: • Scheduled, non-emergency inpatient hospital stays and residential treatment center admissions (except inpatient hospital stays for maternity care of 48 hours or less following a normal delivery or 96 hours or less following a cesarean section and mastectomy and lymph node dissection) • Transplant services • Visits for physical therapy, physical medicine, occupational therapy and chiropractic care beyond 24 combined visits per calendar year • Home health care; home infusion therapy • Admission to a skilled nursing facility • Surgical treatment for morbid obesity performed at a Centers of Expertise facility • Select imaging procedures including MRI, CAT scan, PET scan, MRS scan, MRA scan and Nuclear Cardiac Imaging • Certain types of Durable Medical Equipment including ultra lightweight wheelchairs, motorized/ power wheelchairs, power operated vehicles and related accessories HMO and PPO providers will initiate a pre-service review on your behalf. Non-PPO providers may initiate the review for you, or you may call Anthem Blue Cross directly at the toll-free telephone number for pre- service review printed on your ID card. It is your responsibility to confirm that the review has been performed. Failure to obtain pre-service authorization for an inpatient hospital or residential treatment center admission or the facility-based care for the treatment of mental or nervous disorders and substance abuse will be subject to a $350 non- certification penalty. Your Cost for Medical Per Pay Period Your cost for Medical is based on your selected plan and coverage category as well as the amount of the City of Los Angeles subsidy. The table below reflects the member cost per pay period effective July 1, 2018. Coverage Category Anthem Blue Cross Prudent Buyer PPO Anthem Blue Cross CaliforniaCare Plus HMO (California Residents Only) Kaiser HMO (California Residents Only) Single $0.00 $0.00 $0.00 2-Party $2.50 $0.00 $0.00 Family $48.50 $50.90 $0.00