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

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© 2011 Wells Fargo Bank, N�A� All rights reserved� TMM201005026 IMS88479 (01/11) v13�0
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Summary Plan Description Anthem Blu
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2 Page intentionally left blank Ant
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Anthem BCBS, CVS Caremark, and Anth
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services described in this SPD� O
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• 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
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Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

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