The Plan covers a broad array of medical services for both Active Members and Retired Members. Active members who use in-network providers through Anthem Blue Cross and Blue Shield pay a modest co-pay that varies by service. Behavioral health and prescription drugs are covered under different programs.

If you choose an out-of-network provider, you will be responsible for 20 percent coinsurance after satisfying an annual deductible of $200 for an individual or $400 for a family. This applies to most medical services and behavioral health claims. The deductible does not apply to prescription drugs. The plan considers amounts submitted for out-of-network claims up to a maximum allowable charge that is based on the Medicare Resource Based Relative Value Scale.

Covered Medical Procedures:The Plan covers only those procedures deemed to be effective and acceptable under current standards of practice. The list of approved procedures is constantly evolving with the development of new, more effective procedures. In some cases the same service may be payable, but with a different code or codes. The commonly used authority on determining whether a procedure should be covered is the listing maintained by Medicare which can be found at:

If you are an Active Member or Retired Member, your provider must file your claims though Anthem Blue Cross and Blue Shield (using your ID card), regardless of whether your practitioner is in-network or out-of-network. If the practitioner is in Connecticut, the claim should be submitted electronically at www.anthem.com. If your provider is located outside of Connecticut, your claim should be submitted through the local Blue Cross and Blue Shield office in that state.

Most Active/Retired Member claims are submitted via electronic means. However, you may submit a claim form for an in-state or out-of-state provider to:

Anthem Blue Cross and Blue Shield

National Account Division

P.O. Box 533

North Haven, CT 06473

Locate a medical provider:

Visit www.anthem.com and go to Find a doctor.