Medical Benefits Overview

For full details about the medical benefits available from the DGA–Producer Health Plan, refer to the March 2020 Health Plan Summary Plan Description, beginning on page 37.

Medical Provider Network

Anthem Blue Cross is the Health Plan’s medical provider network.

To locate a network doctor, click here to go to our Network Provider Finder.

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.

Below is a summarized schedule of medical benefits under the Health Plan.

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

Dependent Premium Amounts

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 2020 Health Plan Summary Plan Description or contact the Plan office at (877) 866-2200 ext. 402.

Reasonable and Customary Charges (R&C)

When you visit a non-network doctor, the Plan office will only consider charges up to the reasonable and customary (R&C) amount for that service. You will be responsible for all charges over the R&C amount.

For example, if your doctor bills you $400 for an office visit, but the R&C is $100, you will be responsible for the entire $300 that is in excess of the R&C amount, plus the applicable co-insurance on the initial $100 and any deductible.

The R&C amount is a charge or fee that is equal to the lesser of: (1) actual billed charges; (2) 150% of the applicable Medicare reimbursement rate for a specified procedure; or (3) in the event there is no Medicare reimbursement rate for a specified procedure or it cannot be determined based on the information submitted, the amount that would be paid to a similar provider for the same or similar service or item in the same geographic location or locality. For doctors outside of the United States, the R&C amount is based on 150% of the applicable Medicare reimbursement rate for a specified procedure in the New York metropolitan area.

The Health Plan’s maximum allowable charge for any medical procedure or service from a non-network provider will not exceed the applicable Reasonable and Customary amount noted above. You are responsible for any charges from non-network providers in excess of the maximum allowable charge and all non-covered expenses, except with respect to emergency services, non-emergency services received from a non-network provider at certain network facilities, and air ambulance services furnished by non-network providers.

Network doctors will not charge you more than the contracted rates for covered services.

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.