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Medi-Cal

Medi-Cal is California's Medicaid program. This is a public health insurance program. It provides health care services for people with low incomes. People served include:

  • Low income individuals
  • Families with children
  • Seniors
  • People with disabilities
  • Children in foster care
  • Pregnant women
  • People with specific diseases such as breast cancer, tuberculosis or HIV/AIDS.

Anthem Blue Cross’ affiliate is contracted with the Department of Health Care Services to provide Medi-Cal health benefits to its Medi-Cal recipients. Anthem Blue Cross is also contracted with the Local Initiative Health Authority of Los Angeles County (L.A. Care).

Benefits Overview

We provide all of your regular Medi-Cal benefits, plus many extras at no cost:

  • Checkups for when you’re sick and well to make sure you get and stay well
  • Referrals from your primary care provider (PCP) when you need specialty care or services
  • 24/7 NurseLine — a nurse help line so you can get help when you need it anytime, day or night
  • Rides to approved medical services and visits
  • Telehealth services so you can discuss your health condition by phone, computer or other technology
  • Special programs for moms-to-be and babies to get and stay healthy
  • Care coordination to help arrange care and services, plus connect you to any extra services you may need. For members with chronic health conditions, this could include enrollment in a Health Homes program in select counties.
  • Health classes and wellness tips
  • A large list of doctors and drugstores to choose from
  • Help in many languages through interpretation services for members who don’t speak English
  • Programs for members with ongoing health concerns like heart disease, diabetes and asthma
  • And more!

Now, you can get outpatient acupuncture services!

These services must be used to:

  • Prevent
  • Modify
  • Get rid of the perception of pain that is:
    • Severe
    • Persistent
    • Three or more ER visits in the last year
    • Chronic
    • Caused by a well-known medical condition

We’ll cover outpatient acupuncture services both with and without electric needle stimulation. You can get two services per calendar month.

For a full list of benefits, please see your member handbook.

Referrals and preapprovals

Referrals

A referral is when your PCP sends you to another provider for care. This care is often from a specialist. You may need to see a specialist for care more than once. Your PCP will:

  • Tell you when you need to visit a specialist.
  • Help choose a specialist to give you the care you need.
  • Help you set up an office visit with a specialist.
  • Give you an Authorization for Referral Services form. Take this form to your specialist. He or she will complete it and send it back to your PCP.

Some types of services are known as self-referral services. That means you can get these services without a referral from your PCP. See your member handbook for a list of these services. Make sure you tell your PCP and specialist as much as you can about your health. This will help them make sure you get the right care. You may also need preapproval from us to get this care.

Preapprovals

We need to give a preapproval (prior authorization) for some types of care. Your PCP will ask Anthem to make sure the services they want to give you are offered. If they are, both Anthem and your PCP or specialist agree the services are medically necessary. Medically necessary means this care will protect your life, keep you from getting seriously ill or disabled, or reduce your severe pain. Getting a preapproval will take five days or up to 14 days if we need more information from you. If urgent, it will take no more than 72 hours.

Types of care that need preapproval include, but are not limited to:

  • All elective and nonurgent inpatient care and admissions
  • Out-of-area or out-of-plan care, except in emergencies
  • Most surgeries, including some outpatient care
  • Gastroenterology procedures, plus upper endoscopy and procedures related to bariatric surgery
  • Inpatient and anesthesia care for dental procedures
  • Transplant services, except cornea; members younger than 21 will be referred to California Children’s Services for transplant care
  • Rehabilitation therapy (respiratory and speech)
  • Some pain management tests and procedures
  • Most behavioral health and substance abuse care, with psychological tests
  • Advanced imaging (MRAs, MRIs, CT, CTA scans)
  • Some prescriptions
  • Home health care, including infusion services
  • Inpatient hospice care
  • Long-term services and supports
  • Some durable medical equipment, including prosthetics and orthotics
  • Experimental and investigational care
  • Transportation, except in an emergency
  • Digital hearing aids
  • Sleep studies
  • Some transgender procedures

We don’t need to give preapproval if you get these types of care from a provider in our plan:

  • Chiropractic care for members residing in Sacramento
  • Dialysis
  • Emergency care
  • Well-woman checkups or obstetrical care
  • Standard X-rays and ultrasounds
  • Physical and occupational therapy from a provider in our plan
  • Formulary glucometers and nebulizers

We don’t need to give preapproval for family planning services. You can get these services from any provider. We do not cover services to get pregnant.

We may not approve payment for a service you or your provider asks for. If your case doesn’t meet the rules for medical necessity, we’ll send you a letter. The letter will tell you we could not approve the service and why. The letter will also let you know how to appeal our decision if you disagree with it.

You can’t be billed by your doctor, hospital or any other provider. You have no copays for:

  • Covered services
  • Drugs prescribed by a doctor for the care and treatment of an injury
  • Drugs not listed on Anthem’s preferred drug list

If you have questions or want to learn more, call us at 1-800-407-4627 (TTY 1-888-757-6034). For members in Los Angeles, call 1-888-285-7801 (TTY 711). Call Monday through Friday, from 7 a.m. to 7 p.m. You can also find more information in your member handbook.

The Health Homes Program

Your health home – Your connection to a healthier you.

The Health Homes Program is a personalized approach to health care. It focuses on you, not your conditions. It’s like having a guide to walk you through the complex health care system — keeping track of all your health and service needs and communicating with your providers.

Learn more.

New Baby, New LifeSM Healthy Rewards Incentives
  • $25 incentive for prenatal visit in the first trimester or within 42 days of enrollment into Anthem Blue Cross
  • $50 incentive for attending a postpartum visit 21-56 days after delivery
  • $50 incentive for attending at least six well-child checkups by 15 months of age. This includes the two-week checkup.
  • For more information, visit mss.anthem.com/healthyrewards or call 1-877-868-2004 (TTY 711).
Pharmacy and Prescription Drugs

Anthem covers a wide range of prescriptions and over-the-counter medicines. You do not have a copay or deductible for prescription drugs.

We will cover your drugs if they are:

  • Ordered by a doctor
  • For the care and treatment of an injury or an illness
  • Approved by us when the drug is not on the Preferred Drug List (PDL)

Searchable Formulary

Search for name-brand and generic drugs that are on the Formulary. You can search for your drug by:

  • Typing the name (at least first three letters) of the drug in the search box.
  • Using the A-Z list to search by the first letter of your drug. OR
  • Clicking on therapeutic class of the drug.

Searchable Formulary

Printable Formulary

You can view and print the whole drug list (formulary) from the links below.

You can use the links below to get more pharmacy information

If you need a drug that isn’t listed on our formulary, you or someone you choose to act for you can request a formulary exception. Just email submitmyexceptionreq@anthem.com.

NOTICE: Rite Aid is no longer part of our plan.

If you get prescriptions from Rite Aid now, you need to choose a new pharmacy. If you want to keep getting your prescriptions from Rite Aid, you may have to pay for your prescriptions out-of-pocket.

To find a pharmacy in our plan:

  1. Go to the Provider Search Tool
  2. Under I’m looking for a: select Pharmacy from the drop down menu
  3. Search by pharmacy name or location

Transferring your prescription is easy.
After you choose a new pharmacy, you can do one of the following:

  • Ask your old or new pharmacy to transfer your prescription
  • Take your prescription bottle to your new pharmacy (as long as it has at least one refill)
  • Ask your doctor to call your new pharmacy

If you need help or have questions, call the Customer Care Center number on your member ID card Monday through Friday from 7 a.m. to 7 p.m. Pacific time.

Timely Access to Care

We want to make sure you get the care you need when you need it. The chart below shows how long you’ll typically wait to see your doctor when you call for an appointment.

If you need interpreter services during your appointment, we offer translations in your own language and sign language. Call the Customer Care Center phone number listed on your ID card to get interpreter services.

Free interpreter and translation services