your resources

FREQUENTLY ASKED QUESTIONS

HMO Guide | Open Enrollment | FMLA | HIPAA | COBRA

HMO Guide

This page summarizes some of the most frequent questions members ask about using your HMO benefits. PacFed is dedicated to providing you with quality health care and service. The more you understand how your Health Plan coverage works, the better your ability to use the services available. The Member Services Department is available to provide you with assistance when you need it. For more information or answers to other questions regarding coverage, please contact the Member Services Department at PacFed Benefit Administrators (PacFed).

The foundation for Health Maintenance Organizations (HMO) is your relationship with your Primary Care Physician. A Primary Care Physician is usually a general practitioner or family practice physician who manages all your health care or medical needs, which includes your basic care, preventive services, referrals to specialist and hospitalization arrangements.

Always contact your Primary Care Physician first for any health care needs. Your Primary Care Physician or associate is available 24 hours a day.

Use the Provider Directory to select a physician nearest to your home or work. Your medical records will be maintained at your selected Primary Care Physician.

You will each receive a medical identification card with you and your eligible dependents selected Primary Care Physician's name, address, phone number and your personal identification number. Carry your card at all times and have it available when you call or visit your doctor.

Your Primary Care Physician, in consultation with his/her colleagues, will determine the proper treatment and refer you to a specialist when needed.

Ask your Primary Care Physician how long the referral authorization takes. If you feel the referral process is taking too long, call the PacFed Member Services Department for assistance.

Remember: All medical care must be coordinated by your Primary Care Physician, or the cost of the service may not be covered.

Yes. You may change Primary Care Physicians once a month. You will need to contact Anthem Blue Cross’s Member Services Department.

Changes made by the 15th of the month to be effective the 1st of the following month.

An emergency is defined as an illness or injury that threatens a person's life.

For non-life threatening conditions you should call the 800 number on the back of your medical identification card for instructions. If your condition is life threatening or may cause permanent damage to your health or limb, call 911. Once your condition is stable you or a family member should call the 800 number on the back of your identification card to report your medical emergency. The Plan must be notified within 48 hours.

Your Medical Plan will cover urgent care or medical emergencies when you are out of the service area. Your co-payment will be slightly higher for urgent care and medical emergencies.

It is possible you may receive a bill in error. If you ever receive a bill for charges other than applicable co-payments, do not pay it. Forward the bill to the PacFed Member Services Department:

PacFed Benefit Administrators
200 S. Los Robles, Suite 320
Pasadena, CA 91101
(818) 243-0222
(800) 753-0222
Fax: (818) 549-0610

MUST has the National Formulary Pharmacy network under CarelonRx. If you are unsure if your Pharmacy is in the network, you can ask your pharmacy or log onto your Anthem account.

Your pharmacy will provide the number of pills prescribed by your physician, not to exceed a 30-day supply. If you are on a maintenance prescription you may obtain a 90-day supply through mail-order.

Make sure any pharmacy you use has your most recent Anthem ID card information on file. This will help to ensure that they have the information they need to quickly and accurately process your prescriptions.

Not sure if you are using your most recent card?
Your ID card has an “Issue Date” on the back corner. As long as your issue date is September 2018 or later, you have your most recent card.

What should I do if I don’t have my most recent card?
First, you can download a digital copy of your ID Card at anthem.com or on the Anthem Anywhere mobile app. You can even use the digital ID card straight from your smartphone at the pharmacy counter.

Second, you can order a new ID card anytime by requesting one online or giving us a call. Just login to Anthem and click on Request ID Card to order a new one. Or call the Member Services number on the back of the ID card you do have. A new ID card will be mailed to your home in about five business days.

Finally, you can also show this FAQs page to your pharmacist. Please ask them to update your record with the information below:

RXBIN: 020099
RXPCN: WG

If you have any questions, please call the Pharmacy Member Services number listed on your ID Card.

Open Enrollment

Open enrollment occurs in January of each year.  This is the time that you may add dependents.  Representatives from PacFed will be available at your worksite to assist you, or you may call PacFed Benefit Administrators at 1-800-753-0222. 

Any changes made during Open Enrollment will become effective February 1st.

Family and Medical Leave Act (FMLA)

Under the Family and Medical Leave Act of 1993 (FMLA), you may be entitled to family or medical leave. If you are eligible and elect to take FMLA leave, your coverage under the Plan will continue with no interruption of active employment until the earlier of the end of such leave, or the date you notify your employer you do not intend to return to work at the end of the FMLA leave. 

Continued active participation in the Plan while on FMLA leave will be at your option. Employers are responsible for funding the same portion of the employee's premium that they paid before FMLA leave. Employees are responsible for funding the same portion of the premium that they paid before the FMLA leave. If you elect not to continue your benefits during the FMLA leave, your coverage will be reinstated without regard to any pre-existing condition limitation on your return to active working status on or before the end of the FMLA leave.

A leave taken under FMLA does not constitute a COBRA qualifying event unless the employee fails to return to work at the end of the FMLA leave. In that case, the last day of FMLA leave would be the qualifying event date for COBRA. You must contact your employer to determine your eligibility for FMLA leave.

If you have any questions about this notice please contact:
PacFed Member Services
1-818-243-0222

HIPAA

Health Insurance Portability and Accountability Act of 1996

The intent of the HIPAA legislation is to improve the availability and portability of health coverage by:

• Restricting preexisting condition exclusions and limitations;

• Providing credit for prior coverage to reduce or eliminate preexisting condition limitations;

• Providing new rights to enroll in plans in situations when other coverage is lost;

• Prohibiting discrimination on the basis of health status; and,

• Guaranteeing the availability and renewability of health coverage for small employers

See more about COBRA in the Summary Plan Description and Summary of Material Modification (SMM).

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. LEARN MORE

COBRA

Consolidated Omnibus Budget Reconciliation Act

Should your coverage through MUST be terminated, due to a COBRA qualifying event, you will have the opportunity to continue your coverage on a self-pay basis.  

See more about COBRA in the Summary Plan Description and Summary of Material Modification (SMM).

QUESTIONS?

MUST is administered by PacFed Benefit Administrators (PacFed). Our bilingual staff can help you with enrollment, coverage and HMO claims.

PacFed’s core goal is to ensure that members understand their plan and how to use their benefits effectively. Our Member Services department is available Monday through Friday, 8:30 a.m. to 5:00 p.m. at 1-800-753-0222 or email Enrollment@PacFed.com.