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 72
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 72
Benefit Description
Organ/Tissue Transplants (cont.)
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
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Basic Option - You Pay
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Organ/Tissue Transplants (cont.)
- 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
See previous page
Basic Option - You Pay
See previous page
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
Organ/Tissue Transplants - continued on next page