Anthem Plan Types and Behavioral Health Coverage

Anthem Blue Cross of California is the largest commercial insurer in the state, and the plan type printed on your Anthem card decides almost everything about how you use your behavioral health benefits. Two people can both have Anthem, both have therapy covered, and still pay very different amounts out of pocket, wait different lengths of time for care, and follow entirely different referral rules.

Anthem sells five main plan structures in California: HMO, PPO, EPO, POS, and HSA-eligible high-deductible plans. Each one determines whether you can self-refer to a therapist, whether you can see an out-of-network clinician, whether you owe a copay or coinsurance, and whether your behavioral health claims are managed by Anthem directly or by its behavioral health administrator (Carelon Behavioral Health, formerly Beacon Health Options).

This guide walks through each Anthem plan type in California, how each one handles therapy and psychiatry, and what to check before you book your first appointment. The goal is to help you understand your own plan well enough to find care without surprise bills.

The Five Main Anthem Plan Types in California

Anthem Blue Cross of California organizes its commercial and individual plans into five main structures. Each structure decides how you access care and how much you pay. The differences matter more for behavioral health than for a physical because therapy is usually a recurring visit, so small per-session cost differences add up over a year.

Note that Anthem also participates in Covered California, the state marketplace, and offers Medi-Cal managed care in several counties. The Covered California plans use the same underlying HMO/PPO/EPO structures. For a full list of plan categories, the California Department of Insurance publishes a plain-language overview at insurance.ca.gov.

How Behavioral Health Coverage Differs Between These Plans

Every Anthem plan sold in California must cover behavioral health at the same benefit level as medical and surgical care. That is the Mental Health Parity and Addiction Equity Act, and the U.S. Department of Labor confirms the rule applies to nearly all employer and marketplace plans at dol.gov. What changes across Anthem plan types is how you reach that care and what you pay when you get there.

Anthem HMO plans route almost all care through your primary care physician. For behavioral health specifically, some HMO plans allow self-referral to a Carelon-managed therapist without a PCP note, but you still must stay in-network. HMOs are common on Covered California silver plans and on some employer plans in Northern California.

Anthem PPO plans give the most flexibility. You can call any in-network therapist or psychiatrist and book without a referral. Out-of-network care is reimbursed at a lower rate, but it is covered. PPOs are the most common employer-sponsored behavioral health plans in California.

Anthem EPO plans look like PPOs (no referral needed) but behave like HMOs on network limits (out-of-network is not covered at all). EPO members should confirm every clinician is in the Anthem network before booking.

Anthem POS plans are a middle path. In-network care runs like an HMO (referral required, low copay). Out-of-network care runs like a PPO (higher deductible and coinsurance, but covered). POS plans are less common but show up on some school district and public sector plans.

Anthem HSA/HDHP plans are structural overlays on any of the above. You pay 100% of the negotiated rate for therapy until you meet the deductible (often $2,000-$3,000 for an individual), then coinsurance applies. Because deductibles reset each year, HSA members often pay the most for early-year therapy sessions and the least for late-year ones.

Referrals, Prior Authorization, and Carelon Behavioral Health

Anthem contracts with Carelon Behavioral Health (formerly Beacon Health Options) to manage most of its behavioral health benefits in California. Carelon runs the therapist directory, processes prior authorization, and pays claims. That means for many Anthem plans your card will list the Anthem logo on the front and a separate mental or behavioral health phone number that routes to Carelon on the back.

A referral is the note from your primary care doctor allowing you to see a specialist. Prior authorization is Carelon or Anthem's approval of a specific service before it happens. Routine outpatient therapy visits almost never require prior authorization, regardless of plan type. What does typically require it: psychological testing, neuropsychological evaluations, ABA therapy for autism, intensive outpatient programs, and any inpatient behavioral health admission.

For HMO and POS plans, the referral rule usually reads: your PCP must submit a referral to Carelon before your first therapy appointment. In practice, many California HMO plans have carved out an exception for outpatient behavioral health so members can self-refer. This exception is authorized by California's SB 855, which requires commercial plans to provide medically necessary mental health and substance use disorder treatment; the California Department of Managed Health Care summarizes it at dmhc.ca.gov.

If a therapist accepts Anthem, they will verify your plan type and referral status before your first visit. Group practices handle this administratively so you do not have to sort out the paperwork. Our walkthrough on how to verify your mental health benefits gives you a script for the exact questions to ask when you call the Carelon number on your card.

Deductibles, Copays, and Coinsurance by Plan Type

Cost-sharing on Anthem behavioral health visits follows the same pattern as medical visits under parity law, but the amounts vary widely by plan. Rather than quote a single number, here is what to expect by structure. All figures below are typical ranges; your own plan documents are the source of truth.

HMO copays are usually the lowest. Expect $10-30 per therapy session with no deductible for outpatient behavioral health. Some HMO plans waive cost-sharing entirely for the first few therapy visits.

PPO copays for in-network therapy typically run $20-50 per session. Out-of-network coinsurance is usually 30-40% after a separate out-of-network deductible.

EPO copays mirror PPO in-network amounts, usually $20-50. Out-of-network visits are not covered, so there is no reimbursement math to run.

HDHP/HSA plans apply the full contracted rate against your deductible for each session until it is met. A typical Anthem PPO contracted rate for a 45-minute therapy session in California runs roughly $110-160, so members can expect to pay that amount out of pocket per session until the deductible clears. After the deductible, coinsurance of 10-20% typically applies.

For a full walkthrough of these three cost-sharing pieces and how they interact, see our explainer on deductibles, copays, and coinsurance for therapy. If you are debating between in-network and out-of-network, our comparison on in-network vs out-of-network therapy in California covers the practical differences.

How to Read Your Anthem Card and Verify Your Plan Type

Your Anthem member card is the fastest way to identify your plan type. Look at the front, top-right corner: the plan type is usually printed there in small text, sometimes with a suffix like "PPO," "HMO CA Care," "EPO Select," or "Blue Cross HDHP." If you cannot find it on the card, the same information appears on your benefits summary in the Anthem member portal at anthem.com under "My Plan."

Once you know your plan type, verify these specific pieces before booking your first therapy appointment:

• Is behavioral health managed by Carelon or by Anthem directly? The phone number on the back of your card will tell you.
• Do you need a referral from your primary care doctor before your first session?
• Is there a prior authorization requirement for the service you need (relevant for testing and ABA, not routine therapy)?
• What is your in-network copay or coinsurance for outpatient therapy?
• Is your deductible met for the year, or does it apply to therapy visits?
• Is telehealth therapy covered at the same level as in-person?

Anthem members with HMO or POS plans in California should also confirm which medical group they are assigned to. Your medical group can affect which behavioral health network is in-network for you, especially in the Los Angeles and Central Valley markets. The Cigna guide and Aetna guide on our site walk through similar verification steps if you have coverage under those payers.

Common Pitfalls When Using Anthem Behavioral Health Benefits

Most Anthem members hit the same handful of speedbumps when they use their behavioral health benefits for the first time. Knowing them ahead of time makes the process a lot smoother.

Assuming Anthem's directory is accurate. The Anthem or Carelon directory listing for a therapist may be months out of date. Always confirm with the therapist directly that they are in-network with your specific plan and accepting new patients. Directory inaccuracy is a documented industry-wide issue that federal regulators track; the Centers for Medicare and Medicaid Services publishes network adequacy standards at cms.gov.

Not knowing the deductible resets January 1. HDHP and PPO deductibles start over at the beginning of each calendar year. A session that cost you a $30 copay in December might cost you the full $130 contracted rate in January until the new year's deductible is met. Plan your therapy budget accordingly.

Confusing Anthem's California network with BlueCard. If you have an Anthem plan from another state (e.g., Anthem Empire in New York) and you live in California, you access California therapists through the BlueCard program, not Anthem Blue Cross of California directly. Reimbursement rules can differ.

Missing the parity protection. California's SB 855 requires Anthem to cover medically necessary behavioral health treatment. If Anthem denies a service you and your clinician believe is necessary, you have appeal rights, and the California Department of Managed Health Care can help. Consumer information on filing complaints is at dmhc.ca.gov/FileaComplaint. For a payer-specific walkthrough of therapy coverage, see whether Anthem covers therapy in California. When you are ready to start, you can also find care through Lean Medical across our California service areas.

Frequently Asked Questions