2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 71
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 71
Benefit Description
Organ/Tissue Transplants (cont.)
Note: See pages 69-70 for the prior approval and facility requirements that apply to organ/tissue transplants.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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 (cont.)
- 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
See previous page
Basic Option - You Pay
Continued from previous page:
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:
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)
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 - continued on next page