Medical Benefits & Claims - Network

MEDICAL NETWORK MEDICAL BENEFITS PARTNER: ANTHEM BLUE CROSS

Find an Anthem Blue Cross Network Provider

For more detailed provider information, including quality ratings and patient reviews, visit the Anthem Blue Cross Benefits Management Portal at www.anthem.com/ca. (Registration required.)

To reach an Anthem Blue Cross representative by phone, call (800) 810-2583.

SCHEDULE OF MEDICAL BENEFITS

Below is a summarized schedule of medical benefits under the Health Plan.
Network Provider Non-Network Provider
Calendar Year Deductible $325/person; $975/family
Percentage Paid by the Health Plan 90% of covered expenses

DGA Premier Choice Plan
70% of covered expenses

DGA Choice Plan
60% of covered expenses
Calendar Year Out-of-Pocket Limit (in excess of deductible) $1,000 per person

DGA Premier Choice Plan
$12,500 per person

DGA Choice Plan
$20,000 per person
All Inclusive Network Out-of-Pocket Limit (includes deductibles, co-insurance and co-payments [including prescription drug co-payments])

$10,600 per person
$21,200 family 		Not applicable

*Co-payments and network preventive care services do not count towards the calendar year deductible..

DEPENDENT PREMIUM AMOUNTS

Enrollment Annual Premium
Participant Only No premium
Participant + 1 Dependent $780
Participant + 2 more Dependents $1,200

NON-COVERED SERVICES

Most medically necessary services are covered by the Health Plan. However, not all services provided by a doctor are covered (cosmetic surgery, for example). You are responsible for 100% of the cost of non-covered services.

Do not assume that all services performed by a network doctor are covered. Some network doctors offer non-covered, medical services.

The best way to determine if a treatment is covered is to refer to the March 2025 Health Plan Summary Plan Description or contact the Plan office at (877) 866-2200 ext. 402.

ADDITIONAL INFORMATION ABOUT NETWORK DOCTORS

Network doctors are not required to refer you to other network doctors. In a non-emergency situation, you should check to see if your referral is for a network doctor. You can do so by contacting the doctor directly or by checking the Anthem Blue Cross Network Provider Finder.

Services in a network hospital may be performed by non-network doctors.

We cannot guarantee that there will always be a network provider available for the medical service that you need. Some areas do not have network providers. In other areas, a network provider in a specific field of medicine may not be available at all times.

FILING A NETWORK MEDICAL CLAIM

NO CLAIM NEEDED FOR NETWORK MEDICAL PROVIDERS

If you use a network provider, you do not need to submit a claim to Anthem Blue Cross (for claims incurred in CA) or the appropriate Blue Cross Blue Shield office (for claims incurred outside of CA). Your network doctor, hospital or other provider will automatically accept assignment of benefits and bill directly to Anthem Blue Cross or the appropriate Blue Cross Blue Shield office. All you have to do is pay the appropriate co-insurance and deductible, if applicable.

A NEW COORDINATION OF BENEFITS FORM IS REQUIRED EACH YEAR

If you have not completed a Coordination of Benefits form within the past year, you will need to do so before your claims can be processed. Each year, a Coordination of Benefits form is mailed to you during your open enrollment period. If the Health Plan has not received a current Coordination of Benefits form, even if your information has not changed, your claim may be denied.