What is Anthem Blue Cross EPO? A Complete Guide

Anthem Blue Cross EPO is a type of health insurance plan offered by Anthem Blue Cross in California. EPO stands for Exclusive Provider Organization. This plan provides access to care within a defined network of doctors, hospitals, and other healthcare providers.

What is an EPO Plan?

An EPO, or Exclusive Provider Organization, is a managed care plan that provides health coverage through a network of participating healthcare providers. Here are some key things to know about EPO plans:

Limited Network: EPOs have a more limited network compared to PPOs. You can only get care from doctors, hospitals, and other providers that are in the EPO network. Going out-of-network results in no coverage except for emergencies.
No Referrals: You don’t need referrals to see specialists within the EPO network. You have direct access to any in-network specialist.
Copays for Services: You pay a fixed copay amount for services like doctor visits, rather than coinsurance percentages. Copays are usually lower than coinsurance.
Pre-Authorization: Some services may require pre-authorization or approval from the insurance company before receiving care. This helps ensure the service is medically necessary.
No Out-of-Network Coverage: There are no out-of-network benefits except for emergency care. All non-emergency care must be received from in-network providers.

The main advantage of EPO plans is the lower copays for services compared to plans with coinsurance, like PPOs. The tradeoff is the smaller network and lack of out-of-network coverage.

Anthem Blue Cross EPO Plan Details

Anthem Blue Cross offers EPO plans for individuals and employer groups in California. Here are some key details on Anthem’s EPO offerings:

Plan Options: Anthem has different EPO plan options based on deductible amount, copays, and out-of-pocket maximums. Popular options include plans with $0 deductible and office visit copays around $20-40.
Provider Network: Anthem’s EPO plans utilize the EPO provider network. This is smaller than the PPO network but includes doctors, hospitals, and facilities across California.
Prescription Drugs: Prescriptions are covered through a partnership with EmpiRx Health. Copays vary based on tier (generic, preferred brand, non-preferred brand, specialty).
Pediatric Vision: Pediatric vision benefits are included for members under age 19. This covers vision exams and eyeglasses through VSP Vision.
Pediatric Dental: Pediatric dental benefits are included for members under age 19. This covers dental check-ups, basic services, and major procedures through Anthem’s dental network.
Telehealth: Telehealth visits through LiveHealth Online are covered with a $0 copay, allowing access to doctors 24/7 via phone or video chat.
Nurseline: Members have 24/7 access to Anthem’s nurseline for health questions or guidance on where to seek care.
Preventive Care: In-network preventive care like annual physicals, immunizations, cancer screenings are covered at no charge.
No Referrals: No referrals are needed to see specialists in the EPO network.

How Anthem Blue Cross EPO Works

Here is an overview of how coverage, costs, and billing work with an Anthem Blue Cross EPO:

Finding Providers: You can search for EPO providers on Anthem’s website or mobile app. Only providers in the EPO network will be covered.
ID Cards: Members receive Anthem ID cards to present when receiving medical care or filling prescriptions.
Copays & Deductibles: You pay copays for services like doctor visits. If the plan has a deductible, you pay 100% until meeting the deductible.
Out-of-Pocket Maximum: All plans have an annual limit on your total costs including deductible, copays, and coinsurance.
Claims & Billing: In-network providers bill Anthem directly. You just pay the copay. There’s no claim paperwork.
Pre-Authorization: Some services require pre-approval from Anthem. In-network providers handle this process.
Explanation of Benefits: You receive an EOB from Anthem explaining what was billed, paid, and your responsibility.
No Out-of-Network Coverage: All non-emergency services must be received from in-network EPO providers. Going out-of-network results in no coverage.

Pros and Cons of Anthem Blue Cross EPO

Here are some of the key advantages and disadvantages of Anthem’s EPO plans:

Pros

Lower copays for doctor visits and services
No deductible on many plans
Direct access to in-network specialists
Large California provider network
Coverage for prescription drugs
Pediatric dental and vision benefits

Cons

Limited provider network
Pre-authorization required for some services
No out-of-network coverage except emergencies
May need to change doctors if your current provider is not in-network

Who is Eligible for Anthem Blue Cross EPO?

Anthem Blue Cross EPO plans are available to both individuals and employer groups in California.

For individuals, Anthem EPO plans can be purchased through Covered California, the state’s health insurance marketplace. These comply with Affordable Care Act regulations.

For employer groups, Anthem EPO plans are available to companies with 2-100 employees in California. The company selects the plan(s) to offer employees.

How Much Does Anthem Blue Cross EPO Cost?

The monthly premiums for Anthem EPO plans vary based on:

Plan Type: Plans with lower deductibles and copays have higher monthly premiums. Plans with higher deductibles have lower premiums.
Age: Premiums are higher for older members and lower for younger members. This is due to the increased cost of care as you age.
Dependents: Adding dependents like a spouse or children increases the premium.
Region: Premiums are also based on your rating region. Cost of care varies in different parts of California.
Subsidies: Individuals buying through Covered California may qualify for subsidies to reduce monthly premiums based on income.

Exact premium costs depend on these factors. Anthem Blue Cross EPO plans provide a balance of comprehensive medical benefits alongside lower out-of-pocket costs compared to many other plan types.

Finding Anthem Blue Cross EPO Doctors

Since EPO plans have a defined provider network, it’s important to search ahead of time to find in-network doctors near you. Here are some tips:

Check Anthem’s online provider search tool on their website. You can filter by specialty, location, and other criteria.
Search as you would as a member to see in-network results. You don’t need an account to browse the network.
Look for your current physicians or find new ones based on reviews, hospital affiliations, accepted insurance, and other factors.
Search for specialists like cardiologists, dermatologists, OB/GYNs, therapists, and others you want access to.
Check Hepatitis C providers if applicable, as Anthem has a specialty network for Hep C treatment.
Call Anthem if you have trouble finding an in-network provider for specific care needs.

Searching providers ahead of time ensures you can continue seeing current doctors you trust, or find new ones covered under the EPO plan. This avoids surprises down the road after enrolling.

Enrolling in Anthem Blue Cross EPO

Enrollment processes vary depending on if you are enrolling through an employer or as an individual.

For employer plans, sign up during your open enrollment period, or within 30 days if newly eligible. Your employer will provide instructions. You can contact your employer’s benefits administrator with any questions.

For individual plans, you enroll through Covered California during the annual open enrollment period each fall or if you have a qualifying life event allowing special enrollment. You can compare Anthem EPO options alongside other carriers and apply online through CoveredCA.com.

Finding the Right Anthem Blue Cross EPO Plan

As you evaluate Anthem EPO options, consider factors like:

Monthly Premiums: Balance premium cost with the deductible and copays that make sense for your budget.
Deductible: Some EPO plans have $0 deductible while others have deductibles from $1,000 – $4,000. Choose based on expected medical spending.
Copays: What copays for primary care, specialists, drugs, and ER visits are affordable for your situation? Compare across plans.
Network: Make sure the doctors and hospitals you want to use are in the EPO network. Check specialist access too.
Benefits: Review covered services, exclusions, and limits to ensure the plan meets your

Anthem Blue Cross EPO Review: Pros and Cons

FAQ

What is the difference between Anthem EPO and PPO?

What Is An EPO (Exclusive Provider Organization) Plan? An EPO is a hybrid of an HMO and a PPO. EPOs generally offer a little more flexibility than an HMO and are usually less expensive than a PPO. Like a PPO, you won’t need a referral to get care from a specialist.

What does EPO mean on an insurance plan?

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Is a PPO better than an EPO?

A PPO offers more flexibility with limited coverage or reimbursement for out-of-network providers. An EPO is more restrictive, with less coverage or reimbursement for out-of-network providers. For budget-friendly members, the cost of an EPO is typically lower than a PPO.

Is EPO a good health plan?

The choice between EPOs and other health plans often comes down to cost, choice and flexibility. An EPO is a “middle ground” plan with medium rates and the ability to go directly to a specialist without a referral. However, your specialist must be part of your EPO plan network for those services to be covered.