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 72
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 72
- Blood or marrow stem cell transplants (adult and pediatric) listed in this section
- Related transplant services previously listed
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 Section 3).
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 Section 3).
Note: Benefits for intestinal, pancreas, pediatric lung, and heart-lung transplants are not available through Blue Distinction Centers for Transplants.
Note: See Section 5(c) for our benefits for facility care.
Note: See Section 5(c) for our benefits for facility care.
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 previously defined
- 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 previously described
- 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
Benefit Description
Anesthesia
Anesthesia (including acupuncture) for covered medical or surgical services when requested by the attending physician and performed by:
Professional services provided in:
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: Nothing
Participating/Non-participating: You pay all charges
Anesthesia
Anesthesia (including acupuncture) for covered medical or surgical services when requested by the attending physician and performed by:
- A certified registered nurse anesthetist (CRNA), or
- A physician other than the physician (or the assistant) performing the covered medical or surgical procedure
Professional services provided in:
- Hospital (inpatient)
- Hospital outpatient department
- Skilled nursing facility
- Ambulatory surgical center
- Residential treatment center
- Office
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: Nothing
Participating/Non-participating: You pay all charges
Anesthesia - continued on next page