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

Hospital inpatient
The Plan covers BlueCard PPO providers Out-of-network providers
• Semiprivate room and board and
general nursing care (private room
is covered only when medically
necessary)
• Intensive care and other special
care units
• Operating, recovery, and treatment
rooms
• Anesthesia
• Prescription drugs and supplies used
during a covered hospital stay
• Lab and x-ray diagnostic imaging
You pay 20% after you satisfy
the deductible�
Other notes:
• Please see the “Notifcation requirements” section on
page 7�
• You must use a BlueCard PPO provider to obtain the
highest level of coverage�
• The Plan covers cornea transplants� For other kinds
of transplants, refer to the “Organ and bone marrow
transplant coverage” section on page 26�
• The Plan covers anesthesia and inpatient hospital
charges for dental care provided to a covered person
who is a child under age fve, is severely disabled, or
has a medical condition that requires hospitalization
or general anesthesia for dental treatment� Please
refer to the “Dental care” section on page 15�
• For cardiac care, you have the option of using Blue
Distinction Centers for Cardiac Care� Call Customer
Service before receiving cardiac care services for
a list of Blue Distinction Centers� These facilities
have been selected through a rigorous evaluation of
clinical data, including outcomes of care� Institutions
that are a part of the cardiac programs are also
subject to periodic reevaluation as criteria continue
to evolve� Blue Distinction Centers for Cardiac Care
provide a full range of cardiac care services, including
inpatient cardiac care, cardiac rehabilitation, cardiac
catheterization (including percutaneous coronary
interventions), and cardiac surgery (including
coronary artery bypass graft surgery)�
If you live more than 50 miles from a Blue
Distinction Center for Cardiac Care, please see the
“Transportation and lodging” section on page 36�
20
You pay 40% after you satisfy
the deductible�
• For bariatric services, you must use Blue Distinction
Centers for Bariatric Surgery� Call Customer Service
before receiving bariatric care services for a list of
Blue Distinction Centers� These facilities have been
selected through a rigorous evaluation of clinical
data, including outcomes of care� Institutions
that are a part of the bariatric programs are also
subject to periodic reevaluation as criteria continue
to evolve� Blue Distinction Centers for Bariatric
Surgery provide a full range of bariatric surgical care
services, including inpatient care, postoperative care,
follow-up, and patient education�
• The Plan covers many of the charges incurred for
transgender surgery (gender reassignment surgery)
for covered persons who meet all of the conditions
for coverage� Contact Anthem BCBS for information
about conditions for coverage� Transgender surgery
benefts are limited to one gender reassignment per
person per lifetime�
• For transgender surgery benefts, the criteria for
diagnosis and treatment are based on the guidelines
set forth by the World Professional Association for
Transgender Health (WPATH), formerly known as
the Harry Benjamin International Gender Dysphoria
Association, Inc� (HBIGDA)�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
Not covered:
• Communication services�
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan