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

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54 Page intentionally left blank Anthem Blue Cross Blue Shield PPO Plan
Chapter 4 Mental health and substance abuse benefts If you enroll in the Anthem BCBS PPO Plan, you and your covered dependents have coverage for in- and out-of-network mental health and substance abuse services described in this chapter� As always, it is between you and your provider to determine the treatments and procedures that best meet your needs� The terms of this chapter control what, if any, benefts are available under the Plan for the mental health or substance abuse services you receive� The fact that a provider has performed or prescribed a procedure or treatment, or the fact that it may be the only treatment for a particular sickness or mental illness, does not mean that it is a covered mental health or substance abuse service� The defnition of a covered health service under the Plan relates only to what is covered and may difer from what your provider deems to be a necessary health service� For mental health or substance abuse treatment to be a covered health service, Anthem BCBS Behavioral Health must determine that the treatment meets the Anthem BCBS Behavioral Health coverage criteria guidelines� Anthem BCBS Behavioral Health Anthem BCBS Behavioral Health (ABH) is the claims administrator for mental health and substance abuse benefts described in this chapter under this Anthem BCBS PPO Plan, and provides confdential referrals for managed mental health and substance abuse care� The ABH network includes psychiatrists, psychologists, and master’s level licensed therapists� Anthem Behavioral Health is stafed 24 hours a day, 365 days a year� For more information, see the “Contacts” section on page 1� To receive benefts through ABH, you must follow the process described in this chapter� Anthem Blue Cross Blue Shield PPO Plan 55
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Summary Plan Description Anthem Blu
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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 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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