Services and Supplies
The Plan provides benefits for the following Medically Necessary services or supplies:
  • Hospital room and board at the hospital's regular daily semi-private rate.
  • Other hospital supplies and services (other than personal items) while you are a registered bed patient.
  • The difference between the hospital's regular daily semi-private rate and the rate for intensive care.
  • Services and supplies (other than personal items) furnished by a hospital to you as an outpatient.
  • Outpatient surgical services. This includes Medically Necessary services rendered in a freestanding ambulatory surgical facility, a short-stay surgical unit or an outpatient department of a hospital.
  • Medical or surgical services of a physician.
  • Services of a registered nurse who does not normally reside in your home and who is not related to you by blood or marriage.
  • Inpatient prescription drugs and medicines.
  • Diagnostic X-rays and lab exams.
  • Anesthetics and oxygen and their administration.
  • X-ray, radium and radioactive isotope therapy and physiotherapy.
  • Administration of whole blood and blood plasma; whole blood and blood plasma, even though not donated or replaced.
  • Rental or purchase of durable medical equipment (such as hospital beds and wheelchairs) which is ordered by a physician, approved by Anthem Blue Cross, determined by Anthem Blue Cross to be Medically Necessary, 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 plans.
  • Professional ambulance service directly to and from the hospital when Medically Necessary.
  • Services of a licensed physical therapist during a covered inpatient hospital or skilled nursing facility confinement. Professional services of a licensed physical therapist, other than a close relative or someone who resides in your home.
  • Medically Necessary chiropractic care.
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.