2024 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 69
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 69
Benefit Description
Organ and Tissue Transplants (cont.)
Autologous blood or marrow stem cell transplants limited to the diagnoses and stages 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
Organ and Tissue Transplants (cont.)
Autologous blood or marrow stem cell transplants limited to the diagnoses and stages indicated below:
- Acute myeloid leukemia
- Autoimmune - limited to: Idiopathic (juvenile) rheumatoid arthritis, multiple sclerosis (treatment-refractory relapsing with high risk of future disability) and Scleroderma/systemic sclerosis
- Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors (PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)
- Chronic lymphocytic leukemia (e.g., T cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia)
- Ewing sarcoma
- Germ cell tumors (e.g., testicular germ cell tumors)
- High-risk or relapsed neuroblastoma
- Hodgkin lymphoma
- Non-Hodgkin lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Osteosarcoma
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, plasma cell leukemia, POEMS – (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome)
- Wilms Tumor
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
Benefit Description
Blood or marrow stem cell transplants for the diagnoses below, only when performed as part of a clinical trial that meets the transplant program prior approval criteria and the requirements listed in the bullets 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.
Blood or marrow stem cell transplants for the diagnoses below, only when performed as part of a clinical trial that meets the transplant program prior approval criteria and the requirements listed in the bullets below.
- Allogeneic blood or marrow stem cell transplants for:
- Autoimmune - limited to scleroderma/systemic sclerosis, systemic lupus erythematosus, CIDP – (chronic inflammatory demyelinating polyneuropathy), and Idiopathic (Juvenile) rheumatoid arthritis
- Breast cancer
- Germ Cell Tumors
- High-risk or relapsed neuroblastoma
- Lysosomal metabolic diseases: e.g., Mucopolysaccharidosis type II (Hunter syndrome); Mucopolysaccharidosis type IV (Morquio syndrome); Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome), Fabry disease, Gaucher disease
- Autoimmune - limited to scleroderma/systemic sclerosis, systemic lupus erythematosus, CIDP – (chronic inflammatory demyelinating polyneuropathy), and Idiopathic (Juvenile) rheumatoid arthritis
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.
Organ and Tissue Transplants - continued on next page