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

Chiropractic care
The Plan covers
Chiropractic care
(26 visits per calendar year maximum)
BlueCard PPO providers
You pay 20% after you satisfy
the deductible�
Other notes: Not covered:
• Please see the “Notifcation requirements” section on
page 7�
• You must use a BlueCard PPO provider to obtain the
highest level of coverage�
• Chiropractic care is limited to a maximum beneft of
26 visits per person per calendar year for all, in- and
out-of-network, providers combined�
• Ofce visits include medical history, medical
examination, medical decision making, counseling,
coordination of care, nature of presenting problem,
and chiropractor’s time�
• You pay all charges that exceed the allowed
amount as determined by BCBS when you use
an out-of-network provider�
14
Out-of-network providers
You pay 40% after you satisfy
the deductible�
• Vocational rehabilitation, except when medically
necessary and provided by an eligible health
care provider�
• Services for or related to recreational therapy
(defned as the prescribed use of recreational or
other activities as treatment interventions to improve
the functional living competence of persons with
physical, mental, emotional, or social disadvantages),
or educational therapy (defned as special education
classes, tutoring, and other nonmedical services
normally provided in an educational setting), or forms
of nonmedical self-care or self-help training, including
but not limited to health club memberships, aerobic
conditioning, therapeutic exercises, work-hardening
programs, and massage therapy, and all related
material and products for these programs�
• Services for or related to rehabilitation services
that are not expected to make measurable or
sustainable improvement within a reasonable period
of time, unless they are medically necessary and
part of specialized maintenance therapy to treat
the condition�
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan