Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Beneft features Limitations and maximums
Annual out-of-pocket maximums*
• BlueCard PPO providers
Excludes out-of-network deductible,
out-of-network coinsurance amounts,
and mail-order or retail prescription
drug expenses
• Out-of-network providers
Excludes charges above the allowed
amount, in-network deductible, in-network
coinsurance amounts, and mail-order
or retail prescription drug expenses
Lifetime Maximum
$2,300, including deductible, per person per calendar year
$4,600, including deductible, per family per calendar year
$4,400, including deductible, per person per calendar year
$8,800, including deductible, per family per calendar year
• Infertility services $10,000 lifetime maximum beneft per person
(see the “Infertility and fertility” section on page 22)
• Total benefts paid to all providers combined No maximum (except for infertility services)
* Expenses paid by a participant toward covered medical services described in “Chapter 2: Anthem Blue Cross Blue Shield PPO Plan” starting on
page 5 and covered mental health and substance abuse services described in “Chapter 4: Mental health and substance abuse benefts” starting
on page 55 are applied toward the Plan’s annual deductible and annual out-of-pocket maximums� Expenses paid by a participant toward covered
prescription drugs described in “Chapter 3: Prescription drug beneft” starting on page 45 are not applied toward the Plan’s annual deductible and
annual out-of-pocket maximums�
What the Plan covers
The Anthem BCBS PPO Plan covers medically
necessary services as determined by Anthem BCBS
medical policy and specifc Plan provisions� In
the absence of specifc medical policy, medically
necessary covered services are health care services
that a physician, exercising prudent clinical judgment,
would provide to a patient for the purpose of
preventing, evaluating, diagnosing, or treating an
illness, injury, disease, or its symptoms, and that are
determined by Anthem BCBS, at its discretion, to be all
of the following:
• In accordance with generally accepted standards of
medical practice
• Clinically appropriate in terms of type, frequency,
extent, site, and duration and considered efective for
the patient’s illness, injury, or disease
• Not primarily for the convenience of the patient,
physician, or other health care provider and not
more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis
or treatment of that patient’s illness, injury, or disease
For these purposes, “generally accepted standards
of medical practice” means standards that are
based on creditable scientifc evidence published in
peer-reviewed medical literature generally recognized
by the relevant medical community, Physician Specialty
Society recommendations, and the views of physicians
practicing in relevant clinical areas and any other
relevant factors�
When more than one defnition or provision applies to
a service, the most restrictive applies and exclusions
take precedence over general benefts descriptions�
The Plan only covers care provided by health care
professionals or facilities licensed, certifed, or
otherwise qualifed under state law to provide health
care services and acting within the scope of their
licensureship or certifcation�
Please refer to the following pages for a more detailed
description of Plan benefts�
Anthem Blue Cross Blue Shield PPO Plan 11