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

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�
• If more than one surgical procedure is performed
during the same operative session, the Plan covers
the surgical procedures based on the allowed
amount for each procedure� The Plan does not cover
a charge separate from the surgery for pre- and
postoperative care�
• 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)�
• 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�
• A Retail Health Clinic provides medical services for
a limited list of eligible symptoms (e�g�, sore throat
or cold)� If the presenting symptoms are not on the
list, the member will be directed to seek services
from a physician or hospital� Retail Health Clinics are
stafed by eligible nurse practitioners or other eligible
providers that have a practice arrangement with a
physician� The list of available medical services and
treatable symptoms is available at the Retail Health
Clinic� Access to Retail Health Clinic services is
available on a walk-in basis�
• The Plan covers outpatient palliative care for
members with a new or established diagnosis of a
progressive, debilitating illness that 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:
• Charges for Christian Science care in a Christian
Science sanatorium, unless the confnement is for a
condition that would require a person of another faith
to enter a hospital�
• Internet or similar network communications for
the purpose of scheduling medical appointments,
reflling or renewing existing prescription
medications, reporting normal medical test results,
providing education materials, updating patient
information, requesting a referral, and services that
would similarly not be charged for an on-site medical
ofce visit�
• Cosmetic surgery to repair a physical defect�
• Repair of scars and blemishes on skin surfaces�
• Separate charges for pre- and postoperative care
for surgery�
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan 31