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

Maternity
The Plan covers BlueCard PPO providers Out-of-network providers
• Health care professional ofce
visit services for prenatal and
postnatal care
• Outpatient hospital or facility charges
for prenatal and postpartum care
• Inpatient hospital care,
including delivery
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 baby must be enrolled within 60 days after
birth (child must be added to coverage through
Wells Fargo to receive benefts under the Plan� Refer
to “Chapter 1: An introduction to your benefts” in
your Benefts Book)� If the baby is not enrolled during
this time period, you must wait until the next open
enrollment to enroll the child�
• The Plan covers one home health care visit within
four days of discharge from the hospital if either the
mother or the newborn child is confned for a period
less than the 48 hours (or 96 hours) mentioned above�
See the “Home health care” section on page 17�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
You pay 40% after you satisfy
the deductible�
Not covered:
• Adoption�
• Child-birth classes�
• A surrogate’s pregnancy on your behalf and related
obstetric and maternity benefts�
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan 23