Introduction

Important - Take the time to read this section carefully, so that you and your eligible dependents will know how to use the Indemnity Plan to your full advantage.

By learning a few basics, your out-of-pocket costs will be substantially reduced. Thus, key terms and concepts in this section are highlighted in bold print.

For additional assistance in understanding how to use the Indemnity Plan, there is a separate Question and Answer section. This section is composed of questions most frequently asked by members about the Plan.

The Board of Trustees have contracted with Anthem Blue Cross of California for the purpose of making the expansive Anthem Blue Cross PPO network available to Employees and their eligible dependents who are covered for benefits under the Indemnity Plan.  Anthem Blue Cross also pays all claims under this Plan.  All questions concerning your benefits, including information regarding your claims should be directed to Anthem Blue Cross at: (800) 543-3037.

Anthem Blue Cross has established a network of "Participating Providers." These providers are called "participating" because they have agreed to participate in the Anthem Blue Cross preferred provider organization program, called PPO for short.

The Anthem Blue Cross PPO is called the Prudent Buyer Plan. Therefore, whenever you see the term "Prudent Buyer" just remember it is the Anthem Blue Cross PPO.

When you think of PPO, you probably think of Anthem Blue Cross Prudent Buyer doctors and hospitals, which is correct. There are other health care providers, which are neither physicians nor hospitals. The Anthem Blue Cross Prudent Buyer Plan includes an expanded list of providers in addition to doctors and hospitals. For example, ambulatory surgical centers, home health care agencies, home infusion therapy providers, skilled nursing facilities, and medical products and services. All Participating Providers are listed in the Prudent Buyer directory, which is available from the Administrative Office.

A Prudent Buyer Plan directory is available for each of seven areas within the state of California. For example, there are separate directories for each of the following areas: Los Angeles County, Orange County and Inland Empire, Tri-Counties (San Luis Obispo/Santa Barbara/Ventura), and Bay Area Counties. You can find Prudent Buyer participating providers throughout the state of California.

Recognizing that there are sometimes changes between printings, it is your responsibility to verify current Prudent Buyer status before you obtain services. Remember to ask your doctor if he is a Anthem Blue Cross Prudent Buyer Participating Provider. You can also phone the Administrative Office for assistance in identifying or locating a Prudent Buyer doctor, hospital, or other health care provider.  Also refer to the section entitled "On-Line Internet Website – Anthem Blue Cross."

Anthem Blue Cross will supply you with an Identification Card, which identifies you as being eligible to use the Prudent Buyer Plan network of Participating Providers. Of course, to be eligible for Plan benefits you must work the required hours and be eligible for benefits as explained in the Eligibility section in the table of contents titled "Eligibility & General Plan Provisions".

When you use a Prudent Buyer Provider you will realize substantial savings and have less out-of-pocket expense as opposed to going to a non-participating provider. This is because Prudent Buyer providers have agreed to provide health care at a special low cost, and these savings are passed along to you.

IMPORTANT, the amount of benefits payable under the Plan will be different for participating providers (Prudent Buyer) than for non-participating providers. When you use a Prudent Buyer provider, you will be reimbursed (subject to Plan deductibles and covered charges) ninety percent (90%) of the special Prudent Buyer negotiated rate. Thus, your out-of-pocket expense will be ten percent (10%) of the negotiated rate. There are coinsurance limits under the Plan after which the Plan will pay one hundred percent (100%) of covered charges. Refer to section "Self Funded Indemnity Plan" which explains the co-insurance limit of the Plan.

Additional savings may be realized when using a Prudent Buyer doctor, because Prudent Buyer providers refer only within the Prudent Buyer provider network. For example, should you need to see a specialist, your Prudent Buyer primary care physician will refer you to a doctor who is also a Prudent Buyer Participating Provider. Again, remember to always verify that a doctor or other health care provider is a member of the Prudent Buyer network.

Non-participating providers are providers, which have not agreed to participate in the Prudent Buyer Plan network. They have not agreed to the negotiated rates and other provisions of a Prudent Buyer Plan contract.

When you use a non-participating provider you will only be reimbursed (subject to Plan deductibles and covered charges) eighty percent (80%), based on a fixed schedule of benefits. There is the same coinsurance limit under the Plan, however the Plan will only reimburse you based on eighty percent (80%) of the schedule of allowances.

Refer to the section titled "Commonly Asked Questions and Answers" which gives an example of what the Plan will pay and what your out-of-pocket expense might be comparing a Prudent Buyer provider claim to a non-participating provider with the same charges.