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 73
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 73
Benefit Description
Organ/Tissue Transplants (cont.)
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 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
Organ/Tissue Transplants (cont.)
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 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
Organ/Tissue Transplants - continued on next page