2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Organ/Tissue Transplants
Section 5. Benefits
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Organ/Tissue Transplants
Organ/Tissue Transplants
Prior approval requirements:
You must obtain prior approval (see page 23) from the Local Plan, for both the procedure and the facility, for the transplant procedures listed below. Prior approval is not required for transplants of corneal tissue.
Note: Refer to pages 21-22 for information about precertification of inpatient care.
Prior approval requirements:
You must obtain prior approval (see page 23) from the Local Plan, for both the procedure and the facility, for the transplant procedures listed below. Prior approval is not required for transplants of corneal tissue.
- Blood or marrow stem cell transplant procedures (Note: Pages 73-74 have additional requirements that apply to blood or marrow stem cell transplants that are covered only as part of a clinical trial.)
- Autologous pancreas islet cell transplant
- Heart transplant
- Implantation of an artificial heart as a bridge to transplant or destination therapy
- Heart-lung transplant
- Intestinal transplants (small intestine with or without other organs)
- Kidney
- Liver transplant
- Lung (single, double, or lobar) transplant
- Pancreas transplant
Note: Refer to pages 21-22 for information about precertification of inpatient care.
Covered organ/tissue transplants are listed on pages 70-71. Benefits are subject to medical necessity and experimental/investigational review, and to the prior approval requirements shown above.
Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.
If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not apply and you may use any covered facility that performs the procedure. If Medicare offers an approved program for an anticipated organ transplant, but your facility is not approved by Medicare for the procedure, please contact your Local Plan at the customer service phone number on the back of your ID card.
Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.
If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not apply and you may use any covered facility that performs the procedure. If Medicare offers an approved program for an anticipated organ transplant, but your facility is not approved by Medicare for the procedure, please contact your Local Plan at the customer service phone number on the back of your ID card.
Blood or marrow stem cell transplants are covered as shown on pages 71-75. Benefits are limited to the stages of the diagnoses listed.
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on pages 71-75, the medical necessity limitation is considered satisfied if the patient meets the staging description.
The blood or marrow stem cell transplants listed on pages 71-75 must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility. The transplant procedures listed on page 74 must be performed at a FACT-accredited facility. See page 19 for more information about these types of facilities.
Not every facility provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the facility is specifically designated or accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number listed on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
Note: Coverage for the blood or marrow stem cell transplants described on pages 71-72 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to pages 73-74 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Note: We provide enhanced benefits for covered transplant services performed at Blue Distinction Centers for Transplants (see page 76 for more information).
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on pages 71-75, the medical necessity limitation is considered satisfied if the patient meets the staging description.
The blood or marrow stem cell transplants listed on pages 71-75 must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility. The transplant procedures listed on page 74 must be performed at a FACT-accredited facility. See page 19 for more information about these types of facilities.
Not every facility provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the facility is specifically designated or accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number listed on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
Note: Coverage for the blood or marrow stem cell transplants described on pages 71-72 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to pages 73-74 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Note: We provide enhanced benefits for covered transplant services performed at Blue Distinction Centers for Transplants (see page 76 for more information).
Benefit Description
Organ/Tissue Transplants
Note: See pages 69-70 for the prior approval and facility requirements that apply to organ/tissue transplants.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: You may request prior approval and receive specific benefit information in advance for corneal transplants to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Organ/Tissue Transplants
- Transplants of corneal tissue
- Heart transplant
- Heart-lung transplant
- Kidney transplant
- Liver transplant
- Pancreas transplant
- Combination liver-kidney transplant
- Combination pancreas-kidney transplant
- Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
- Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
- Single, double, or lobar lung transplant
- For members with end-stage cystic fibrosis, benefits for lung transplantation are limited to double lung transplants
- Implantation of an artificial heart as a bridge to transplant or destination therapy
Note: See pages 69-70 for the prior approval and facility requirements that apply to organ/tissue transplants.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: You may request prior approval and receive specific benefit information in advance for corneal transplants to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Benefit Description
Allogeneic blood or marrow stem cell transplants for the diagnoses as indicated below:
Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.
Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Allogeneic blood or marrow stem cell transplants for the diagnoses as indicated below:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with poor response to therapy, short time to progression, transformed disease, or high-risk disease
- Chronic myelogenous leukemia
- Hemoglobinopathy (i.e., sickle cell anemia, thalassemia major)
- High-risk neuroblastoma
- Hodgkin’s lymphoma
- Infantile malignant osteopetrosis
- Inherited metabolic disorders (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome and Maroteaux-Lamy syndrome variants)
- Marrow failure (i.e., severe or very severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure red cell aplasia, congenital thrombocytopenia)
- MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))
- Myelodysplasia/myelodysplastic syndromes (MDS)
- Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis)
- Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome)
- Primary immunodeficiencies (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, hemophagocytic lymphohistiocytosis, X-linked lymphoproliferative syndrome, Kostmann’s syndrome, leukocyte adhesion deficiencies)
Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.
Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Benefit Description
Autologous blood or marrow stem cell transplants for the diagnoses as indicated below:
Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.
Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Autologous blood or marrow stem cell transplants for the diagnoses as indicated below:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors (PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)
- Ewing’s sarcoma
- Germ cell tumors (e.g., testicular germ cell tumors)
- High-risk neuroblastoma
- Hodgkin’s lymphoma
- Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome)
- Scleroderma
Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.
Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Benefit Description
Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed as part of a clinical trial that meets the facility criteria described on page 69-70 and the requirements listed on page 74:
Note: If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown on page 74 is not available, we will arrange for the transplant to be provided at an approved transplant facility, if available.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed as part of a clinical trial that meets the facility criteria described on page 69-70 and the requirements listed on page 74:
- Allogeneic blood or marrow stem cell transplants for:
- Breast cancer
- Colon cancer
- Epidermolysis bullosa
- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
- Ovarian cancer
- Prostate cancer
- Renal cell carcinoma
- Retinoblastoma
- Rhabdomyosarcoma
- Sarcoma
- Wilm’s tumor
- Breast cancer
- Autologous blood or marrow stem cell transplants for:
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- Chronic myelogenous leukemia
- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
- Retinoblastoma
- Rhabdomyosarcoma
- Wilm’s tumor and other childhood kidney cancers
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
Note: If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown on page 74 is not available, we will arrange for the transplant to be provided at an approved transplant facility, if available.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Benefit Description
Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed at a FACT-accredited facility (see page 19) as part of a clinical trial that meets the requirements listed below:
Requirements for blood or marrow stem cell transplants covered only under clinical trials:
Note: Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed at a FACT-accredited facility (see page 19) as part of a clinical trial that meets the requirements listed below:
- Allogeneic blood or marrow stem cell transplants for:
- Autoimmune disease (limited to: multiple sclerosis, scleroderma, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
- Autoimmune disease (limited to: multiple sclerosis, scleroderma, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
- Autologous blood or marrow stem cell transplants for:
- Autoimmune disease (limited to: multiple sclerosis, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
Requirements for blood or marrow stem cell transplants covered only under clinical trials:
- You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see page 23); and
- The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
- For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board (IRB) of the FACT-accredited facility where the procedure is to be performed; and
- For the transplant procedures listed on page 73, the clinical trial must be reviewed and approved by the IRB of the FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility where the procedure is to be performed.
- For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board (IRB) of the FACT-accredited facility where the procedure is to be performed; and
Note: Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Benefit Description
Related transplant services:
Note: See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Related transplant services:
- Extraction or reinfusion of blood or marrow stem cells as part of a covered allogeneic or autologous transplant
- Harvesting, immediate preservation, and storage of stem cells when the autologous blood or marrow stem cell transplant has been scheduled or is anticipated to be scheduled within an appropriate time frame for patients diagnosed at the time of harvesting with one of the conditions listed on pages 71-74
Note: Benefits are available for charges related to fees for storage of harvested autologous blood or marrow stem cells related to a covered autologous stem cell transplant that has been scheduled or is anticipated to be scheduled within an appropriate time frame. No benefits are available for any charges related to fees for long term storage of stem cells.
- Collection, processing, storage, and distribution of cord blood only when provided as part of a blood or marrow stem cell transplant scheduled or anticipated to be scheduled within an appropriate time frame for patients diagnosed with one of the conditions listed on pages 71-74
- Covered medical and hospital expenses of the donor, when we cover the recipient
- Covered services or supplies provided to the recipient
- Donor screening tests for non-full sibling (such as unrelated) potential donors, for any full sibling potential donors, and for the actual donor used for transplant
Note: See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting
Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings
Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.
Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.
Participating/Non-participating: You pay all charges
Organ/Tissue Transplants at Blue Distinction Centers for Transplants®
We participate in the Blue Distinction Centers for Transplants Program for the organ/tissue transplants listed below.
Members who choose to use a Blue Distinction Center for Transplants for a covered transplant only pay the $350 per admission copayment under Standard Option, or the $250 per day copayment ($1,500 maximum) under Basic Option, for the transplant period. See page 159 for the definition of “transplant period.” Members are not responsible for additional costs for included professional services.
Regular benefits (subject to the regular cost-sharing levels for facility and professional services) are paid for pre- and post-transplant services performed in Blue Distinction Centers for Transplants before and after the transplant period and for services unrelated to a covered transplant.
All members (including those who have Medicare Part A or another group health insurance policy as their primary payor) must contact us at the customer service phone number listed on the back of their ID card before obtaining services. You will be referred to the designated Plan transplant coordinator for information about Blue Distinction Centers for Transplants.
We participate in the Blue Distinction Centers for Transplants Program for the organ/tissue transplants listed below.
Members who choose to use a Blue Distinction Center for Transplants for a covered transplant only pay the $350 per admission copayment under Standard Option, or the $250 per day copayment ($1,500 maximum) under Basic Option, for the transplant period. See page 159 for the definition of “transplant period.” Members are not responsible for additional costs for included professional services.
Regular benefits (subject to the regular cost-sharing levels for facility and professional services) are paid for pre- and post-transplant services performed in Blue Distinction Centers for Transplants before and after the transplant period and for services unrelated to a covered transplant.
All members (including those who have Medicare Part A or another group health insurance policy as their primary payor) must contact us at the customer service phone number listed on the back of their ID card before obtaining services. You will be referred to the designated Plan transplant coordinator for information about Blue Distinction Centers for Transplants.
- Heart (adult and pediatric)
- Kidney (adult and pediatric)
- Liver (adult and pediatric liver alone; adult only for combination liver-kidney)
- Single or double lung (adult only)
- Blood or marrow stem cell transplants (adult and pediatric) listed on pages 71-74
- Related transplant services listed on page 75
Travel benefits:
Members who receive covered care at a Blue Distinction Center for Transplants for one of the transplants listed above can be reimbursed for incurred travel costs related to the transplant, subject to the criteria and limitations described here.
We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant for the member and companions. If the transplant recipient is age 21 or younger, we pay up to $10,000 for eligible travel costs for the member and companions. Reimbursement is subject to IRS regulations.
Note: You must obtain prior approval for travel benefits (see page 23).
Members who receive covered care at a Blue Distinction Center for Transplants for one of the transplants listed above can be reimbursed for incurred travel costs related to the transplant, subject to the criteria and limitations described here.
We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant for the member and companions. If the transplant recipient is age 21 or younger, we pay up to $10,000 for eligible travel costs for the member and companions. Reimbursement is subject to IRS regulations.
Note: You must obtain prior approval for travel benefits (see page 23).
Note: Benefits for cornea, intestinal, pancreas, pediatric lung, and heart-lung transplants are not available through Blue Distinction Centers for Transplants. See pages 70-71 for benefit information for these transplants.
Note: See Section 5(c) for our benefits for facility care.
Note: See pages 70-76 for requirements related to blood or marrow stem cell transplant coverage.
Note: See Section 5(c) for our benefits for facility care.
Note: See pages 70-76 for requirements related to blood or marrow stem cell transplant coverage.
Benefit Description
Organ/Tissue Transplants
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Organ/Tissue Transplants
Not covered:
- Any transplant not listed as covered and transplants for any diagnosis not listed as covered
- Donor screening tests and donor search expenses, including associated travel expenses, except as defined on page 75
- Implants of artificial organs, including those implanted as a bridge to transplant and/or as destination therapy, other than medically necessary implantation of an artificial heart as described on pages 70-71
- Allogeneic pancreas islet cell transplantation
- Travel costs related to covered transplants performed at facilities other than Blue Distinction Centers for Transplants; travel costs incurred when prior approval has not been obtained; travel costs outside those allowed by IRS regulations, such as food-related expenses
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges