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

Physical therapy, occupational therapy, speech therapy
The Plan covers BlueCard PPO providers Out-of-network providers
Limited to 90 visits per calendar year, in and out of
network, and combined for the following:
• Rehabilitative physical therapy
• Rehabilitative occupational therapy
• Rehabilitative speech therapy to restore:
– Previously attained speech function that has
become impaired as a result of a congenital defect
for which corrective surgery has been performed
– Previously attained speech function that has
become impaired as a result of injury or sickness
except for a mental or personality disorder
• Cardiac rehabilitation therapy
• Pulmonary rehabilitation therapy
• Habilitative speech therapy provided by a licensed
speech therapist to a child member who has failed to
acquire the skills expected of a person of the same
age as a result of:
– A development delay
– Hearing impairment
– Major congenital anomalies that afect speech such
as but not limited to cleft lip and cleft palate
– Habilitative-related therapies are covered through
the end of the year of a participant’s 18th birthday
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�
• For lab and diagnostic imaging services billed
by a health care professional, please refer to the
“Outpatient surgery and diagnostic and therapeutic
services” section on page 28� For lab and diagnostic
imaging services billed by a facility, please refer to
the “Hospital inpatient” section on page 20 or the
“Hospital outpatient” section on page 21�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
• In addition to the limitations noted above, therapies
must also meet Anthem BCBS criteria for medical
necessity�
You pay 20% after you satisfy
the deductible�
You pay 40% after you satisfy
the deductible�
Speech therapy is also covered for developmental delay
for children through the calendar year in which your
child turns age 18�
Example: If your child turns 18 years old on
May 17, 2010, he or she will continue to be covered
through December 31, 2010�
Not covered:
• 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, 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 related to developmental delay regardless of
the underlying cause, except as noted under speech
therapy in the table above� Delayed development
means the individual has been unable to acquire the
skills expected of a person of that particular age�
Anthem Blue Cross Blue Shield PPO Plan 29