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

Skilled nursing facility
The Plan covers BlueCard PPO providers Out-of-network providers
• Skilled care ordered by a
physician and eligible under
Medicare guidelines
• Semiprivate room and board
• General nursing care
• Prescription drugs used during a
covered admission
• Physical, occupational, and
speech therapy
You pay 20% after you satisfy
the deductible�
You pay 40% after you satisfy
the deductible�
Other notes: Transportation and lodging
• Please see the “Notifcation requirements” section on
page 7�
• You must use a BlueCard PPO provider to obtain the
highest level of coverage�
• Coverage is limited to a maximum beneft of 100 day
visits per person per calendar year combined with
home health care and extended skilled nursing, up to
24 hours per day, in- and out-of-network�
• If you are unable to obtain a bed in a BlueCard PPO
skilled nursing facility within a 50-mile radius of
your home due to full capacity, you may be eligible to
receive services at an out-of-network skilled nursing
facility at the BlueCard PPO level of coverage�
• 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 or related to care that is custodial or not
normally provided as preventive care or for treatment
of an illness or injury�
• Treatment, services, or supplies that are not
medically necessary�
• Private-duty nursing (see the “Extended
skilled nursing care” section on page 18 for
more information)�
• Please refer to the “General exclusions” section on
page 38�
36
For bariatric surgery, cardiac care, or organ and
bone marrow transplants, Anthem BCBS will assist
the patient and family with travel and lodging
arrangements if the patient meets the criteria to
receive services and resides more than 50 miles from
a Center of Excellence� The travel beneft is subject to a
lifetime maximum of $10,000�
Lodging
The following daily limits apply for lodging:
• Up to $50 per day for the patient or the caregiver if
the patient is in the hospital�
• Up to $100 per day for the patient and one caregiver�
When a child is the patient, two persons may
accompany the child; however, the daily rate for
lodging remains at up to $100 per day�
Transportation
Eligible expenses include:
• Automobile mileage, reimbursed at the standard IRS
medical rate� Efective January 1, 2009, the rate is
24 cents per mile�
• Taxi fares are covered; all receipts must be submitted�
Note: Automobile rental and gas are not
covered expenses.
• Economy or coach airfare (anything other than
economy or coach airfare is not covered)
• Parking
• Trains
• Boat
• Bus
• Tolls
Anthem Blue Cross Blue Shield PPO Plan