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

Reconstructive surgery
The Plan covers BlueCard PPO providers Out-of-network providers
• Reconstructive surgery for prompt
repair of accidental injury that occurs
while covered under the Plan�
• Reconstructive surgery that is
incidental to or following surgery
resulting from sickness or other
diseases of the involved body part� The
surgery must be required because the
primary physiological function has
been impaired due to the disease or
illness and the purpose of the surgery
is to restore the primary physiological
function of the body part on which the
surgery will be performed�
• Reconstructive surgery performed on a
dependent child because of congenital
disease or anomaly that has resulted in
a functional defect as determined by
the attending physician�
• Treatment of cleft lip and palate�
• Elimination or maximum feasible
treatment of port-wine stains�
For the level of coverage, see the
“Hospital inpatient” section on
page 20, the “Hospital outpatient”
section on page 21, and the
“Physician services” section on
page 30�
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�
• Under the Federal Women’s Health and Cancer
Rights Act of 1998, you are entitled to the following
services: reconstruction of the breast on which
the mastectomy was performed; surgery and
reconstruction of the other breast to produce
a symmetrical appearance; and prosthesis and
treatment for physical complications during all stages
of mastectomy, including swelling of the lymph
glands (lymphedema)� Services are provided in a
manner determined in consultation with the physician
and patient� These mastectomy-related benefts are
subject to deductible and coinsurance limitations that
are consistent with those applicable to other medical
and surgical benefts under the PPO option�
• Bone grafting for the purpose of reconstruction of
the jaw and for treatment of cleft lip and palate is
a covered service, but not for the sole purpose of
supporting a dental implant, dentures, or dental
prosthesis�
• You pay all charges that exceed the allowed amount
as determined by Anthem BCBS when you use an
out-of-network provider�
Not covered:
For the level of coverage, see the
“Hospital inpatient” section on
page 20, the “Hospital outpatient”
section on page 21, and the
“Physician services” section on
page 30�
• Dentures, regardless of the cause or condition,
and any associated services or charges, including
bone grafts�
• Dental implants and any associated services
and charges�
• Repair of scars and blemishes on skin surfaces�
• Services related to teeth, the root structure of teeth,
or supporting bone and tissue, except as noted in the
“Dental care” section on page 15�
• Please refer to the “General exclusions” section on
page 38�
Anthem Blue Cross Blue Shield PPO Plan 35