Resources / Materials
Los Angeles
- Los Angeles ANOC - English (PDF)
- Los Angeles ANOC - Español (PDF)
- Los Angeles ANOC - Arabic العربية (PDF)
- Los Angeles ANOC - Armenian Հայերեն (PDF)
- Los Angeles ANOC - Cambodian ខ្មែរ (PDF)
- Los Angeles ANOC - Chinese Mandarin 中文 (PDF)
- Los Angeles ANOC - Farsi/Persian فارسی (PDF)
- Los Angeles ANOC – Korean 한국어 (PDF)
- Los Angeles ANOC - Russian Русский язык (PDF)
- Los Angeles ANOC - Tagalog (PDF)
- Los Angeles ANOC - Vietnamese Tiếng Việt (PDF)
San Diego
Los Angeles
- Los Angeles Summary of Benefits - English (PDF)
- Los Angeles Summary of Benefits - Spanish - Español (PDF)
- Los Angeles Summary of Benefits - Arabic - العربية (PDF)
- Los Angeles Summary of Benefits - Armenian - Հայերեն (PDF)
- Los Angeles Summary of Benefits - Cambodian - ខ្មែរ (PDF)
- Los Angeles Summary of Benefits - Chinese Mandarin - 中文 (PDF)
- Los Angeles Summary of Benefits - Farsi/Persian - فارسی (PDF)
- Los Angeles Summary of Benefits - Korean - 한국어 (PDF)
- Los Angeles Summary of Benefits - Russian - Русский (PDF)
- Los Angeles Summary of Benefits - Tagalog (PDF)
- Los Angeles Summary of Benefits - Vietnamese - Tiếng Việt (PDF)
San Diego
Los Angeles
- Los Angeles Member Handbook - English (PDF)
- Los Angeles Member Handbook - Spanish (PDF)
- Los Angeles Member Handbook - Arabic العربية (PDF)
- Los Angeles Member Handbook - Armenian Հայերեն (PDF)
- Los Angeles Member Handbook - Cambodian ខ្មែរ (PDF)
- Los Angeles Member Handbook - Chinese 中文 (PDF)
- Los Angeles Member Handbook - Farsi/Persian فارسی (PDF)
- Los Angeles Member Handbook - Korean 한국어 (PDF)
- Los Angeles Member Handbook - Russian Русский язык (PDF)
- Los Angeles Member Handbook - Tagalog (PDF)
- Los Angeles Member Handbook - Vietnamese Tiếng Việt (PDF)
San Diego
Procedure Code |
Procedure Description |
C9050 |
EMAPALUMAB-LZSG |
J0129 |
ABATACEPT INJECTION |
J0178 |
AFLIBERCEPT INJECTION |
J0584 |
BUROSUMAB-TWZA 1M |
J0585 |
ONABOTULINUMTOXINA |
J0604 |
CINACALCET, ESRD ON DIALYSIS |
J0717 |
CERTOLIZUMAB PEGOL INJ 1MG |
J0800 |
CORTICOTROPIN INJECTION |
J0897 |
DENOSUMAB INJECTION |
J1300 |
ECULIZUMAB INJECTION |
J1428 |
ETEPLIRSEN, 10 MG |
J1459 |
IVIG PRIVIGEN 500 MG |
J1555 |
CUVITRU, 100 MG |
J1556 |
IMM GLOB BIVIGAM, 500MG |
J1557 |
GAMMAPLEX INJECTION |
J1559 |
HIZENTRA INJECTION |
J1561 |
GAMUNEX-C/GAMMAKED |
J1566 |
IMMUNE GLOBULIN, POWDER |
J1568 |
OCTAGAM INJECTION |
J1569 |
GAMMAGARD LIQUID INJECTION |
J1572 |
FLEBOGAMMA INJECTION |
J1575 |
HYQVIA 100MG IMMUNEGLOBULIN |
J1599 |
IVIG NON-LYOPHILIZED, NOS |
J1602 |
GOLIMUMAB FOR IV USE 1MG |
J1745 |
INFLIXIMAB (REMICADE) |
J1930 |
LANREOTIDE INJECTION |
J2323 |
NATALIZUMAB INJECTION |
J2350 |
OCRELIZUMAB, 1 MG |
J2353 |
OCTREOTIDE INJECTION, DEPOT |
J2357 |
OMALIZUMAB INJECTION |
J2503 |
PEGAPTANIB SODIUM INJECTION |
J2778 |
RANIBIZUMAB INJECTION |
J3262 |
TOCILIZUMAB, 1 MG |
J3304 |
TRIAMCINOLONE ACE XR 1MG |
J3357 |
USTEKINUMAB SUB CU 1 MG |
J3380 |
VEDOLIZUMAB |
J3396 |
VERTEPORFIN INJECTION |
J7189 |
FACTOR VIIA |
J7318 |
DUROLANE 1 MG |
J7320 |
GENVISC 850, 1MG |
J7321 |
HYALGAN SUPARTZ VISCO-3 DOSE |
J7322 |
HYMOVIS INJECTION 1 MG |
J7323 |
EUFLEXXA INJ PER DOSE |
J7324 |
ORTHOVISC INJ PER DOSE |
J7325 |
SYNVISC OR SYNVISC-ONE |
J7326 |
GEL-ONE |
J7327 |
MONOVISC INJ PER DOSE |
J7328 |
GELSYN-3 INJECTION 0.1 MG |
J7329 |
TRIVISC 1 MG |
J9022 |
ATEZOLIZUMAB,10 MG |
J9145 |
INJECTION DARATUMUMAB 10 MG |
J9173 |
DURVALUMAB, 10 MG |
J9176 |
ELOTUZUMAB, 1MG |
J9308 |
RAMUCIRUMAB |
J9311 |
RITUXIMAB, HYALURONIDASE |
J9355 |
TRASTUZUMAB INJECTION |
Q2043 |
SIPULEUCEL-T AUTO CD54+ |
Q5103 |
INFLIXIMAB (INFLECTRA) |
Q5104 |
INFLIXIMAB (RENFLEXIS) |
Quiz
Los Angeles
- Quiz - English (PDF)
- Quiz - Spanish (PDF)
- Quiz - Armenian - Հայերեն (PDF)
- Quiz - Cambodian - ខ្មែរ (PDF)
- Quiz - Chinese - 中文 (PDF)
- Quiz - Hmong - Hmoob (PDF)
- Quiz - Korean - 한국어 (PDF)
- Quiz - Russian - Русский (PDF)
- Quiz - Vietnamese - Tiếng Việt (PDF)
Fact Sheet
Los Angeles
- Fact Sheet - English (PDF)
- Fact Sheet - Spanish (PDF)
- Fact Sheet - Armenian - Հայերեն (PDF)
- Fact Sheet - Cambodian - ខ្មែរ (PDF)
- Fact Sheet - Chinese - 中文 (PDF)
- Fact Sheet - Hmong - Hmoob (PDF)
- Fact Sheet - Korean - 한국어 (PDF)
- Fact Sheet - Russian - Русский (PDF)
- Fact Sheet - Vietnamese - Tiếng Việt (PDF)
Checklist
Los Angeles
- Checklist - English (PDF)
- Checklist - Spanish (PDF)
- Checklist - Armenian - Հայերեն (PDF)
- Checklist - Cambodian - ខ្មែរ (PDF)
- Checklist - Chinese - 中文 (PDF)
- Checklist - Hmong - Hmoob (PDF)
- Checklist - Korean - 한국어 (PDF)
- Checklist - Russian - Русский (PDF)
- Checklist - Vietnamese - Tiếng Việt (PDF)
Benefit Highlights
Los Angeles
- Benefit Highlights - English (PDF)
- Benefit Highlights - Spanish (PDF)
- Benefit Highlights - Armenian - Հայերեն (PDF)
- Benefit Highlights - Cambodian - ខ្មែរ (PDF)
- Benefit Highlights - Chinese - 中文 (PDF)
- Benefit Highlights - Hmong - Hmoob (PDF)
- Benefit Highlights - Korean - 한국어 (PDF)
- Benefit Highlights - Russian - Русский (PDF)
- Benefit Highlights - Vietnamese - Tiếng Việt (PDF)
Care Coordination
Los Angeles
- Care Coordination - English (PDF)
- Care Coordination - Spanish (PDF)
- Care Coordination - Armenian - Հայերեն (PDF)
- Care Coordination - Cambodian - ខ្មែរ (PDF)
- Care Coordination - Chinese - 中文 (PDF)
- Care Coordination - Hmong - Hmoob (PDF)
- Care Coordination - Korean - 한국어 (PDF)
- Care Coordination - Russian - Русский (PDF)
- Care Coordination - Vietnamese - Tiếng Việt (PDF)
Los Angeles Directories
- Provider & Pharmacy Directory Vol. 1 - Los Angeles County, CA Region: Antelope Valley; San Fernando Valley (less Burbank and Glendale) - English (PDF)
- Provider & Pharmacy Directory Vol. 2 - Los Angeles County, CA Region: Burbank, Glendale - English (PDF)
- Provider & Pharmacy Directory Vol. 3 - Los Angeles County, CA Region: San Gabriel Valley (South / West) - English (PDF)
- Provider & Pharmacy Directory Vol. 4 - Los Angeles County, CA Region: San Gabriel Valley (North / East) - English (PDF)
- Provider & Pharmacy Directory Vol. 5 - Los Angeles County, CA Region: Metro (North / East) - English (PDF)
- Provider & Pharmacy Directory Vol. 6 - Los Angeles County, CA Region: Metro (South / West) - English (PDF)
- Provider & Pharmacy Directory Vol. 7 - Los Angeles County, CA Region: West and South LA - English (PDF)
- Provider & Pharmacy Directory Vol. 8 - Los Angeles County, CA Region: East LA (West) - English (PDF)
- Provider & Pharmacy Directory Vol. 9 - Los Angeles County, CA Region: East LA (East) - English (PDF)
- Provider & Pharmacy Directory Vol. 10 - Los Angeles County, CA Region: South Bay - English (PDF)
San Diego Directories
National Coverage Determination Notice
- National Coverage Determination Notice - English (PDF)
- National Coverage Determination Notice - Spanish (PDF)
- National Coverage Determination Notice - Arabic - العربية (PDF)
- National Coverage Determination Notice - Armenian - Հայերեն (PDF)
- National Coverage Determination Notice - Chinese - 中文 (PDF)
- National Coverage Determination Notice - Cambodian - ខ្មែរ (PDF)
- National Coverage Determination Notice - Farsi/Persian - فارسی (PDF)
- National Coverage Determination Notice - Korean - 한국어 (PDF)
- National Coverage Determination Notice - Russian - Русский (PDF)
- National Coverage Determination Notice - Tagalog (PDF)
- National Coverage Determination Notice - Vietnamese - Tiếng Việt (PDF)
Los Angeles and San Diego
Updated 10/09/19
- List of Drugs - English (PDF)
- List of Drugs - Spanish (PDF)
- List of Drugs - Arabic (PDF)
- List of Drugs - Armenian (PDF)
- List of Drugs - Chinese Mandarin (PDF)
- List of Drugs - Cambodian (PDF)
- List of Drugs - Farsi/Persian (PDF)
- List of Drugs - Korean (PDF)
- List of Drugs - Russian (PDF)
- List of Drugs - Tagalog (PDF)
- List of Drugs - Vietnamese (PDF)
Mail Order Pharmacy
- CVS Caremark Mail Order Form - English (PDF)
- CVS Caremark Mail Order Form - Spanish (PDF)
- Homescripts Mail Order Form - English (PDF)
- Homescripts Mail Order Form - Spanish (PDF)
Medication Therapy Management
Prescription Claims
Transition of Care Form
Scope of Appointment
Notice of Privacy Practices
- Notice of Privacy Practices - English (PDF)
- Notice of Privacy Practices - Spanish (PDF)
- Notice of Privacy Practices - Arabic - العربية (PDF)
- Notice of Privacy Practices - Armenian - Հայերեն (PDF)
- Notice of Privacy Practices - Cambodian - ខ្មែរ (PDF)
- Notice of Privacy Practices - Chinese - 中文 (PDF)
- Notice of Privacy Practices - Farsi/Persian - فارسی (PDF)
- Notice of Privacy Practices - Korean - 한국어 (PDF)
- Notice of Privacy Practices - Russian - Русский (PDF)
- Notice of Privacy Practices - Tagalog (PDF)
- Notice of Privacy Practices - Vietnamese - Tiếng Việt (PDF)
Authorization to Disclose Protected Health Information
- Authorization to Disclose Protected Health Information - English (PDF)
- Authorization to Disclose Protected Health Information - Spanish (PDF)
- Authorization to Disclose Protected Health Information - Arabic - العربية (PDF)
- Authorization to Disclose Protected Health Information - Armenian - Հայերեն (PDF)
- Authorization to Disclose Protected Health Information - Cambodian - ខ្មែរ (PDF)
- Authorization to Disclose Protected Health Information - Chinese - 中文 (PDF)
- Authorization to Disclose Protected Health Information - Farsi/Persian - فارسی (PDF)
- Authorization to Disclose Protected Health Information - Korean - 한국어 (PDF)
- Authorization to Disclose Protected Health Information - Russian - Русский (PDF)
- Authorization to Disclose Protected Health Information - Tagalog (PDF)
- Authorization to Disclose Protected Health Information - Vietnamese - Tiếng Việt (PDF)
Confidential Communication Request
- Confidential Communication Request - English (PDF) - coming soon
- Confidential Communication Request - Spanish (PDF)
- Confidential Communication Request - Arabic - العربية (PDF)
- Confidential Communication Request - Armenian - Հայերեն (PDF)
- Confidential Communication Request - Cambodian - ខ្មែរ (PDF)
- Confidential Communication Request - Chinese - 中文 (PDF)
- Confidential Communication Request - Farsi/Persian - فارسی (PDF)
- Confidential Communication Request - Korean - 한국어 (PDF)
- Confidential Communication Request - Russian - Русский (PDF)
- Confidential Communication Request - Tagalog (PDF)
- Confidential Communication Request - Vietnamese - Tiếng Việt (PDF)
Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed your home. Check the catalog for item limits.
Ordering is easy. Just follow the steps in your plan's catalog.