Anthem Blue Cross PPO California?

[britlover 0]

I have my first appointment on Thursday with Dr. McKeen in San Jose. I hear that Blue Cross covers this procedure no problem. The only thing is this Dr. is "out of network". What does this mean in regards to coverage? Do I have to pay a huge chunk? My BMI is 35.4, I'm 5'3'', 200 pounds. I have been told I will be approved by the Dr. no problem. I also have mild sleep apnea, back pain, a dieting does NOT work. I've done all my homework, and am ready. Anybody have any thoughts? Insurance is pretty much a foreign language to me.

[aprildurham23 0]

I have Anthem Blue Cross and Blue Shield and both my husband and mysef got approved for the surgery TODAY! Yay!

BUT, we have an IN-NETWORK doctor, and both our BMI's are over 40. I am 5'2" and 215 (but I was 224 at weigh in). I have no co-morbidities, but I know you MUST have one if your BMI is under 40 to be eligible. You might check around to find an in-network doctor because I'm almost positive you'll have to pay more with him.

We will each have to pay $1,500 out of pocket.

[taylorgirl1 1]

BC Anthem CA If BMI is under 40 you must have a co morbitity for them to approve, ie diabetes needing meds, sleep apnea severe needing Bipap , high bllod pressure, heart disease. They will not consider otherwise. Also surgery must be done at a Bariatric Center of Excellence for them to pay and you co pay will be more if MD is out of network . Go to their website www.anthem.com/ca and you can put in all your info and will tell you exactly what they cover etc

[needtoseemeagain 0]

I am with Anthem also and was advsd the same as taylorgirl ... taylorgirl you sound like you work there! I am so excited just did my labwork yesterday ... I am on the road!

[britlover 0]

Do you guys think having sleep apnea (even if it's mild) will help any? I've also had pretty bad Migraines for years now, and back pain. A friend of mine went to this doctor and her BMI was only 28, and blue cross approved her. It's so frustrating!!

[taylorgirl1 1]

Answers to above no I dont work for Anthem but have spent a lot of time over past 2 years getting everything in order so i know what they need printed stuff off website, also Im an Rn so have some medical knowledge.

Response to other post I had sleep study done ,it showed moderate sleep apnea and BC would not accept it, my diabetes (mild but taking a po med) was what got me approved. Have bad arthritis in knees but they wont consider that either, they care strict about things

Have BMI of 37 weight 200lbs

[Jillbeme65 1]

When you dr is out of network Anthem pays considerably less than what an in network dr will get.. Also if they charge more than an in network dr you will be responsible for the difference. I have to say that I have blue cross anthem ppo and though very shocked they paid everything except 300.00 which was the upfront fee for the dr. My fills are included with the cost of the surgery. I hope this helps

[needtoseemeagain 0]

Once you are registered you can view you benefits, but you can also view Medical Policies and Clinical UM Guidelines in the learn more section when you first go to anthem.com/ca. it is towards the bottom and you can search Lap Band and read all of the details on what will be required.