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

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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
Well-child care Please see the “Preventive care services” section on page 32 for additional information� The Plan covers BlueCard PPO providers Out-of-network providers The following outpatient services for a dependent child from birth to age 18: • Preventive services • Routine developmental assessments • Routine laboratory services • Routine immunizations 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� • You pay all charges that exceed the allowed amount as determined by Anthem BCBS when you use an out-of-network provider� Plan pays 100% for eligible well-child care services, based on U�S� Preventive Services Task Force Guidelines� You pay 40%, no deductible for eligible well-child care services, based on U�S� Preventive Services Task Force Guidelines� Not covered: • Please refer to the exclusions listed in the “Preventive care services” section on page 32 and to the “General exclusions” section on page 38� Anthem Blue Cross Blue Shield PPO Plan 37
Page 1: Summary Plan Description Anthem Blu
Page 4 and 5: ii Page intentionally left blank An
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 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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