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

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ii Page intentionally left blank Anthem Blue Cross Blue Shield PPO Plan
Contacts Questions about the Anthem BCBS PPO Plan Customer Service telephone number Claims administrator: 1-866-418-7749 The claims administrator’s Customer Service staf is available to answer your questions about coverage and direct your calls for preadmission and emergency admission notifcation� Monday – Friday: 7:00 a�m� – 7:00 p�m� Central Time Anthem Blue Cross Blue Shield website anthem�com Use this website to locate providers who participate with Blue Cross and Blue Shield plans nationwide, check out claim information and health programs, or email Customer Service� Information about premiums for the Anthem BCBS PPO Plan Coverage while traveling phone number Medical and behavioral health claims administrator’s mailing address Information about the prescription drug beneft Check your enrollment materials, or go to Teamworks� 1-800-810-BLUE (2583) Use this number to locate BlueCard PPO providers nationwide� For the highest level of benefts, you must use a BlueCard PPO provider� Claims review requests and written inquiries may be mailed to the address below: Anthem Blue Cross Blue Shield PO Box 37010 Louisville, KY 40233 Prior authorization requests should be mailed to the following address: Anthem UM Services, Inc� PO Box 7101 Indianapolis, IN 46207 CVS Caremark 1-800-772-2301 caremark�com Note: When accessing prescription drug benefts, you must use your CVS Caremark ID card. 24/7 NurseLine 1-866-220-4849 Members can receive one-on-one counseling with experienced Anthem nurses� Information about mental health or substance abuse Anthem BCBS Behavioral Health 1-866-621-0554 Employee Assistance Consulting 1-888-327-0027 For TDD access for persons with hearing impairments, please call 1-877-411-0826� Anthem Blue Cross Blue Shield PPO Plan 1
Page 1: Summary Plan Description Anthem Blu
Page 6 and 7: 2 Page intentionally left blank Ant
Page 8 and 9: Anthem BCBS, CVS Caremark, and Anth
Page 10 and 11: services described in this SPD� O
Page 12 and 13: • Left ventricular assist devices
Page 14 and 15: Benefts charts This section lists c
Page 16 and 17: Ambulance The Plan covers BlueCard
Page 18 and 19: Chiropractic care The Plan covers C
Page 20 and 21: Not covered: • Accident-related d
Page 22 and 23: Extended skilled nursing care The P
Page 24 and 25: Hospital inpatient The Plan covers
Page 26 and 27: Infertility and fertility The Plan
Page 28 and 29: Medical equipment, prosthetics, and
Page 30 and 31: Organ and bone marrow transplant co
Page 32 and 33: Outpatient surgery and diagnostic a
Page 34 and 35: • Speech therapy that has not bee
Page 36 and 37: Preventive care services The Plan c
Page 38 and 39: Other notes: • For more informati
Page 40 and 41: Skilled nursing facility The Plan c
Page 42 and 43: General exclusions In addition to a
Page 44 and 45: • Services a provider gives to hi
Page 46 and 47: If you receive services from an out
Page 48 and 49: The plan administrator may delegate
Page 50 and 51: Ordering prescriptions Once you hav
Page 52 and 53: What you’ll pay for prescriptions
Page 54 and 55:
Some drugs require what’s called
Page 56 and 57:
Pre-service claims If the Plan requ
Page 58 and 59:
54 Page intentionally left blank An
Page 60 and 61:
Your benefts and costs at a glance
Page 62 and 63:
Each case will be reviewed, diagnos
Page 64:
© 2011 Wells Fargo Bank, N�A�
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Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

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