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 68
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 68
Benefit Description
Organ and Tissue Transplants
Allogeneic 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
Allogeneic blood or marrow stem cell transplants limited to the diagnoses and stages indicated below:
- Acute lymphocytic or myeloid (e.g., AML promyelocytic) leukemia
- Blastic plasmacytoid dendritic cell neoplasm
- Chronic lymphocytic leukemia (e.g., T cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia)
- Chronic myeloid leukemia
- Hemoglobinopathy (e.g., sickle cell anemia, thalassemia major)
- Hodgkin lymphoma
- Inherited metabolic disorders: Adrenoleukodystrophy, Globoid cell leukodystrophy (Krabbe's leukodystrophy), Metachromatic leukodystrophy, and Mucopolysaccharidosis type I (Hurler syndrome)
- IPEX - immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome
- Marrow failure (e.g., severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure red cell aplasia, congenital thrombocytopenia, Dyskeratosis congenita)
- MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))
- Myelodysplastic syndromes (MDS)
- Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis, Hypereosinophilic syndromes)
- Non-Hodgkin lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Osteopetrosis
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, plasma cell leukemia, POEMS – (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome)
- Primary immunodeficiencies (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, hemophagocytic disorders, X-linked lymphoproliferative syndrome, severe congenital neutropenia, leukocyte adhesion deficiencies, common variable immunodeficiency, chronic granulomatous disease/phagocytic cell disorders)
- Systemic mastocytosis, aggressive
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 - continued on next page