Other Covered Services and Supplies
Other covered services and supplies include:
  • Outpatient professional nursing services of a registered nurse (R.N.), licensed vocational nurse (L.V.N.) or licensed practical nurse (L.P.N.) that are certified as Medically Necessary Covered Health Services by your physician.
  • Services of a licensed midwife working under the direction of a physician. Does not include services of a lay midwife or a doula.
  • Medically Necessary Covered Health Services of a licensed physical or occupational therapist, when provided by someone other than a close relative or someone who resides in your home, when ordered by a physician, and when judged by the physician to be subject to significant improvement through such therapy. The therapy must be expected to result in significant, objective, measurable physical improvement in the covered person's condition within two months of the start of the treatment. Services may be reviewed for medical necessity and must be deemed medically necessary to be covered. After 24 visits in a calendar year, pre-authorization is required. Both physical therapy and occupational therapy visits will be counted on a combined basis when calculating the first 24 visits each calendar year.
  • Non-experimental inpatient drugs and medicines which are approved by the Food and Drug Administration (FDA).
  • Artificial limbs or eyes, when determined to be a Medically Necessary Covered Health Service.
  • Rental or purchase of durable medical equipment (including prosthetic and orthotic devices) that is ordered by a physician, approved by Anthem Blue Cross, determined by Anthem Blue Cross to be a Medically Necessary Covered Health Service, and is to be used solely by the patient. If an item is rented, the rental price for the entire rental period cannot be more than the purchase price. The rented item must be returned if the member switches medical plans. Necessary repairs and maintenance of purchased equipment are also covered if not provided under a manufacturer's warranty or purchase agreement.
  • Wigs and toupees for alopecia areata or alopecia resulting from chemotherapy or radiation therapy.
  • Initial pair of eyeglasses or contact lenses prescribed by a doctor after eye surgery; eyeglasses or lenses when needed to replace loss of the natural lens.
  • Rental of dialysis equipment and all Medically Necessary Covered Health Services and supplies required for hemodialysis treatment.
  • Oxygen, including its administration.
  • Short-term speech therapy services rendered by a certified speech therapist when required due to surgery, illness, injury or previous therapeutic processes, when ordered by a physician, and when judged by the physician to be subject to significant improvement through such therapy. Speech therapy due to functional nervous disorders is not covered. The therapy must be expected to result in significant, objective, measurable physical improvement in the covered person's condition within two months of the start of the treatment. Services may be reviewed for medical necessity and must be deemed medically necessary to be covered. After 24 visits in a calendar year, pre-authorization is required.
  • Diabetes self-management education programs.
  • Surgery to change an individual's appearance when the purpose is:
    • to correct the result of an accidental injury; or
    • to treat a condition, including a birth defect, that impairs the function of a body organ.
  • Diagnostic procedures for the prenatal diagnosis of genetic disorders of the fetus when authorized by a physician in the case of high-risk pregnancy.
  • Surgical treatment of morbid obesity when authorized by a physician and approved by Anthem Blue Cross, when surgical treatment of morbid obesity is necessary to treat another life-threatening condition involving morbid obesity, and when it has been documented that non-surgical treatments of the morbid obesity have failed. Travel expense benefit of up to $3,000 is also available if certain criteria is met in connection with bariatric surgery (see "Transportation and Lodging").
  • Infertility treatments, up to a lifetime maximum of $7,000 combined for all plans administered by Anthem Blue Cross or any prior claim administrators. The benefit includes, but is not limited to, in vitro fertilization services, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and microinjection techniques. Services provided must be considered safe and effective according to accepted clinical evidence reported by generally recognized medical professionals or publications.
  • Transgender surgery, if the surgery meets all the criteria for being deemed Medically Necessary by Anthem Blue Cross. Travel expense benefit of up to $3,000 is also available if certain criteria is met in connection with transgender surgery (see "Transportation and Lodging").
Cancer Clinical Trials
Coverage is provided for services and supplies for routine patient care costs, as defined below, in connection with phase I, phase II, phase III and phase IV cancer clinical trials, if all the following conditions are met:
  • The treatment provided in a clinical trial must either:
    • Involve a drug that is exempt under federal regulations from a new drug application, or
    • Be approved by (i) one of the National Institutes of Health, (ii) the federal Food and Drug Administration in the form of an investigational new drug application, (iii) the United States Department of Defense, or (iv) the United States Veteran's Administration.
  • You must be diagnosed with cancer to be eligible for participation in these clinical trials.
  • Participation in such clinical trials must be recommended by your physician after determining participation has a meaningful potential to benefit the member.
  • For the purpose of this provision, a clinical trial must have a therapeutic intent. Clinical trials to just test toxicity are not included in this coverage.
Routine patient care costs means the costs associated with the provision of services, including drugs, items, devices and services which would otherwise be covered under the plan, including health care services which are:
  • Typically provided absent a clinical trial.
  • Required solely for the provision of the investigational drug, item, device or service.
  • Clinically appropriate monitoring of the investigational item or service.
  • Prevention of complications arising from the provision of the investigational drug, item, device, or service.
  • Reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or treatment of the complications.
Routine patient care costs do not include the costs associated with any of the following:
  • Drugs or devices not approved by the federal Food and Drug Administration that are associated with the clinical trial.
  • Services other than health care services, such as travel, housing, companion expenses and other nonclinical expenses that you may require as a result of the treatment provided for the purposes of the clinical trial.
  • Any item or service provided solely to satisfy data collection and analysis needs not used in the clinical management of the patient.
  • Health care services that, except for the fact they are provided in a clinical trial, are otherwise specifically excluded from the plan.
  • Health care services customarily provided by the research sponsors free of charge to members enrolled in the trial.
Note: You will be financially responsible for the costs associated with non-covered services.
Disagreements regarding the coverage or medical necessity of possible clinical trial services may be subject to Independent Medical Review as described in Grievance Procedures.
  • Coverage for routine mammographies (given as preventative measures to detect problems when a physician does not have a specific reason to suspect a medical problem), in accordance with Anthem Blue Cross' standard administrative policies. Diagnostic mammographies, which are given when there is a suspected problem, are also covered.
  • For a member receiving benefits in connection with a mastectomy and who elects breast reconstruction, the coverage will be provided in a manner determined in consultation with the attending physician and the patient for:
    • reconstruction of the breast on which the mastectomy was performed;
    • surgery and reconstruction of the other breast to produce a symmetrical appearance; and
    • prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
Notify Anthem Blue Cross five business days before receiving services. By notifying Anthem Blue Cross, it can be verified whether a service is a reconstructive procedure or a cosmetic one.
Women's Health and Cancer Rights Act
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
  • All stages of reconstruction of the breast on which the mastectomy was performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance;
  • Prostheses; and
  • Treatment of physical complications of the mastectomy, including lymphedemas.
Coverage of breast reconstruction will be provided subject to the deductibles and coinsurance benefit limits consistent with those established for other benefits under your plan. For more information, contact Anthem Blue Cross directly.
Newborns' and Mothers' Health Protection
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal delivery, or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, plans and insurers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).