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 70
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 70
Benefit Description
Organ and Tissue Transplants (cont.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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.)
- Continued from previous page:
- Renal cell carcinoma
- Sarcoma - Ewing sarcoma, rhabdomyosarcoma, soft tissue sarcoma
- Renal cell carcinoma
- Autologous blood or marrow stem cell transplants for:
- Autoimmune disease - e.g., systemic lupus erythematosus, CIDP (chronic inflammatory demyelinating polyneuropathy), Crohn's disease, Polymyositis-dermatomyositis, rheumatoid arthritis
- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
- Sarcoma (e.g., rhabdomyosarcoma, soft tissue sarcoma)
- Autoimmune disease - e.g., systemic lupus erythematosus, CIDP (chronic inflammatory demyelinating polyneuropathy), Crohn's disease, Polymyositis-dermatomyositis, rheumatoid arthritis
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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
- 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 Section 3); and
- The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
- The clinical trial must be reviewed and approved by the Institutional Review Board IRB of the FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility where the procedure is to be performed.
- You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see Section 3); 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 http://www.cancer.gov/about-cancer/treatment/clinical-trials. If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown above is not available, we will arrange for the transplant to be provided at an approved transplant facility, if available.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance. Note: See Section 9 for our coverage of other costs associated with clinical trials.
Benefit Description
Related transplant services:
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
Related transplant services:
- Extraction or reinfusion of blood or marrow stem cells as part of a covered allogeneic or autologous transplant
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
Organ and Tissue Transplants - continued on next page