Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
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• Services a provider gives to himself or herself or to a<br />
close rel<strong>at</strong>ive (such as a spouse, brother, sister, parent,<br />
grandparent, or child)�<br />
• Services for dependents not covered under the <strong>Plan</strong>�<br />
• Services for or rel<strong>at</strong>ed to:<br />
– Commercial weight-loss programs, fees or dues,<br />
nutritional supplements, food, vitamins, and<br />
exercise therapy, and all associ<strong>at</strong>ed labs, physician<br />
visits, and services rel<strong>at</strong>ed to such programs<br />
40<br />
– Cosmetic health services or reconstructive surgery<br />
and rel<strong>at</strong>ed services and tre<strong>at</strong>ment for conditions<br />
or problems rel<strong>at</strong>ed to cosmetic surgery or services,<br />
except as specifed in the “Reconstructive surgery”<br />
section on page 35<br />
– Dental or oral care, tre<strong>at</strong>ment, orthodontics, or<br />
surgery and any rel<strong>at</strong>ed supplies, anesthesia, or<br />
facility charges, except as specifed in the “Dental<br />
care” section on page 15<br />
– Fetal tissue transplant<strong>at</strong>ion<br />
– Functional capacity evalu<strong>at</strong>ions for voc<strong>at</strong>ional<br />
purposes or determin<strong>at</strong>ion of disability or pension<br />
benefts<br />
– Gene therapy as a tre<strong>at</strong>ment for inherited or<br />
acquired disorders<br />
– Growth hormone, except for conditions th<strong>at</strong> meet<br />
medical necessity criteria as determined by <strong>Anthem</strong><br />
BCBS prior to receipt of the services<br />
– Hearing aids or devices, whether internal, external,<br />
or implantable, and rel<strong>at</strong>ed ftting or adjustments,<br />
except as specifed in the “Medical equipment,<br />
prosthetics, and supplies” section on page 24<br />
– Lenses, frames, contact lenses, and other fabric<strong>at</strong>ed<br />
optical devices or professional services for the<br />
ftting or supply thereof, including the tre<strong>at</strong>ment of<br />
refractive errors such as radial ker<strong>at</strong>otomy, except<br />
as specifed in the “Medical equipment, prosthetics,<br />
and supplies” section on page 24<br />
– Priv<strong>at</strong>e-duty nursing (see the “Extended<br />
skilled nursing care” section on page 18 for<br />
more inform<strong>at</strong>ion)<br />
– Recre<strong>at</strong>ional therapy (defned as the prescribed<br />
use of recre<strong>at</strong>ion and other activities as tre<strong>at</strong>ment<br />
interventions to improve the functional living<br />
competence of persons with physical, mental,<br />
emotional, or social disadvantages) or educ<strong>at</strong>ional<br />
therapy (defned as special educ<strong>at</strong>ion classes,<br />
tutoring, and other nonmedical services normally<br />
provided in an educ<strong>at</strong>ional setting), or forms of<br />
nonmedical self-care or self-help training, including<br />
but not limited to health club memberships, aerobic<br />
conditioning, therapeutic exercises, massage<br />
therapy, and work-hardening programs, and all<br />
rel<strong>at</strong>ed m<strong>at</strong>erial and products for these programs<br />
– Reversal of steriliz<strong>at</strong>ion<br />
– Routine physical exams for purposes of medical<br />
research, obtaining employment or insurance,<br />
or obtaining or maintaining a license of any<br />
type, unless such physical examin<strong>at</strong>ion would<br />
normally have been provided in the absence of the<br />
third-party request<br />
– Smoking cess<strong>at</strong>ion program fees or rel<strong>at</strong>ed program<br />
supplies<br />
– Therapeutic acupuncture, except for the tre<strong>at</strong>ment<br />
of chronic pain when tre<strong>at</strong>ment is provided through<br />
a comprehensive pain management program or for<br />
the prevention and tre<strong>at</strong>ment of nausea associ<strong>at</strong>ed<br />
with surgery, chemotherapy, or pregnancy<br />
– Transport<strong>at</strong>ion other than local ambulance service<br />
to the nearest medical facility equipped to tre<strong>at</strong><br />
the illness or injury, except as specifed in the<br />
“Ambulance” section on page 12<br />
– Tre<strong>at</strong>ment of illness or injury th<strong>at</strong> occurs while<br />
on military duty th<strong>at</strong> is recognized by the<br />
Veterans Administr<strong>at</strong>ion as services rel<strong>at</strong>ed to<br />
service-connected injuries<br />
• Services needed because you engaged in an illegal<br />
occup<strong>at</strong>ion or committed or <strong>at</strong>tempted to commit<br />
a felony�<br />
• Services or confnements ordered by a court or<br />
law enforcement ofcer th<strong>at</strong> are not medically<br />
necessary; services th<strong>at</strong> are not considered medically<br />
necessary include but are not limited to custody<br />
evalu<strong>at</strong>ion, parenting assessment, educ<strong>at</strong>ion classes<br />
for DUI ofenses, competency evalu<strong>at</strong>ions, adoption<br />
home st<strong>at</strong>us, parental competency, and domestic<br />
violence programs�<br />
• Services or supplies th<strong>at</strong> are primarily and<br />
customarily used for nonmedical purposes or used<br />
for environmental control or enhancement (whether<br />
or not prescribed by a physician), including but<br />
not limited to exercise equipment, air purifers, air<br />
conditioners, dehumidifers, he<strong>at</strong> or cold appliances,<br />
w<strong>at</strong>er purifers, hypoallergenic m<strong>at</strong>tresses, w<strong>at</strong>erbeds,<br />
vehicle lifts, computers and rel<strong>at</strong>ed equipment, car<br />
se<strong>at</strong>s, feeding chairs, pillows, food or weight scales,<br />
hot tubs, whirlpools, and incontinence pads or pants�<br />
• Services performed before the efective d<strong>at</strong>e of<br />
coverage and services received after your coverage<br />
termin<strong>at</strong>es, even though your illness started while<br />
your coverage was in force�<br />
<strong>Anthem</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> <strong>Shield</strong> <strong>PPO</strong> <strong>Plan</strong>