What your Anthem Blue Cross contract says

In short

This is a health insurance plan with Anthem Blue Cross, one of California's largest health insurers and part of the national Elevance Health (formerly Anthem, Inc.) family. Unlike Kaiser's closed HMO model, Anthem offers both HMO and PPO plans (PPO plans let you see out-of-network doctors (at a higher cost), while HMO plans require referrals and in-network care). Anthem is available through employers, Covered California, and direct purchase. Your coverage is regulated under California's Knox-Keene Act (for HMO plans) or the California Insurance Code (for PPO plans), both of which provide strong consumer protections including the right to appeal denied claims and request independent medical review.

What you agree to do

• You must pay your monthly premium by the due date to keep your coverage active.
• You must use in-network providers for non-emergency care on HMO plans, or pay significantly more for out-of-network care on PPO plans.
• You must obtain prior authorization for certain procedures, specialist visits, and medications as required by your plan.
• You must pay applicable copays, coinsurance, and deductibles at the time of service.

What you can ask for

• You can go to any emergency room in an emergency (Anthem must cover emergency care regardless of network).
• You can request an Independent Medical Review (IMR) through the DMHC or CDI if Anthem denies a treatment or claim.
• You cannot be denied coverage or charged more because of a pre-existing condition (ACA protection).
• You have the right to receive all ACA-mandated preventive care services with no out-of-pocket cost.

Points worth knowing

• Premium increases at annual renewalAnthem can raise premiums annually. Individual and small group rate increases must be reviewed by the California DMHC or CDI, but increases of 5-15% per year have been common across the industry.
• Out-of-network surprise costs on PPO plansEven on a PPO plan, seeing out-of-network providers can result in much higher costs. While California's AB 72 protects against surprise balance billing in certain scenarios, you may still owe more than expected.
• Prior authorization delaysCertain procedures and medications require prior authorization. If denied, treatment is delayed while you appeal. California law requires Anthem to respond within 5 business days for standard requests and 72 hours for urgent requests.
• Out-of-pocket maximum exposureYou can pay up to your annual out-of-pocket maximum ($9,450 individual / $18,900 family for 2026 ACA plans) before Anthem covers 100%. A hospitalization or complex surgery can reach this limit quickly.
• Network changes can remove your doctorAnthem can change its provider network annually. A doctor or hospital you rely on could leave the network, forcing you to switch providers or pay out-of-network rates.

Dates and deadlines

Open enrollment period

November 1 - January 15 annually for Covered California plans (employer plans have separate windows)

Monthly premium due date

Due on the 1st of each month; 30-day grace period for Covered California plans

Prior authorization response timeline

5 business days for standard requests, 72 hours for urgent requests under California law