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 76
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 76
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