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

Hospital outpatient
The Plan covers BlueCard PPO providers Out-of-network providers
• Scheduled surgery or anesthesia
• Radiation and chemotherapy
• Kidney dialysis
• Respiratory therapy
• Physical, occupational, and
speech therapy
• Lab and x-ray diagnostic imaging
• Diabetes outpatient self-management
training and education, including
medical nutrition therapy
• Palliative care
• All other outpatient hospital care
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 anesthesia and outpatient 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)�
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 outpatient palliative care for
members with a new or established diagnosis of a
progressive, debilitating illness, which may limit the
member’s life expectancy to two years or less� The
services must be within the scope of the provider’s
license to be covered� Palliative care does not include
hospice or respite care�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
Not covered:
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan 21