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 74
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 74
Benefit Description
Organ/Tissue Transplants (cont.)
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.
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 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.
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