2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 22
 
Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.

If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not apply and you may use any covered Preferred facility and Preferred provider that performs the procedure.

Contact us at the customer service telephone number listed on the back of your ID card before obtaining services. We will request the medical evidence we need to make our coverage determination. Our review will include whether you meet the facility and transplant program criteria for the particular transplant.

All members (including those who have Medicare Part A or another group health insurance policy as their primary payor) must contact us at the customer service telephone number listed on the back of their ID card before obtaining services.

 
  • Transplant travel – If you travel to a Blue Distinction Center for Transplants, we reimburse up to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for you and your traveling companions) if you live 50 miles or more from the facility.
 
  • Prescription drugs and supplies – Certain prescription drugs and supplies, including medical foods administered orally (see pages 95 and 133), require prior approval. Contact CVS Caremark, our Pharmacy Program administrator, at 800-624-5060, TTY: 800-624-5077, to request prior approval, or to obtain a list of drugs and supplies that require prior approval. We will request the information we need to make our coverage determination. You must periodically renew prior approval for certain drugs. See page 93 for more information about our prescription drug prior approval program, which is part of our Patient Safety and Quality Monitoring (PSQM) program.
Notes:
 
  • Updates are made periodically throughout the year to the list of drugs and supplies requiring prior approval. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
     
  • Until we approve them, you must pay for these drugs in full when you purchase them – even if you purchase them at a Preferred retail pharmacy or through our specialty drug pharmacy – and submit the expense(s) to us on a claim form. Preferred pharmacies will not file these claims for you.
     
  • The Specialty Drug Pharmacy Program will not fill your prescription until you have obtained prior approval. AllianceRx Walgreens Prime, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be returned to you along with a letter explaining the prior approval procedures.

Warning:

We will reduce our benefits by $100 for medically necessary services that require prior approval, if no one contacts us for prior approval. If the service is not medically necessary, we will not provide benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see above.