2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 68
 
  • Allogeneic blood or marrow stem cell transplants or autologous blood or marrow stem cell transplants for:
    • Autoimmune disease (limited to: multiple sclerosis, scleroderma, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
  • Autologous blood or marrow stem cell transplants for:
    • Autoimmune disease (limited to: multiple sclerosis, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
  • Autologous blood or marrow stem cell transplants for:
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
    • Retinoblastoma
    • Rhabdomyosarcoma
    • Wilm’s tumor and other childhood kidney cancers

Note: A transplant clinical trial may not be available for your condition. If you or your provider are considering a clinical trial, please contact us at the telephone number on the back of your ID card for assistance in determining if a covered clinical trial is available in a covered facility.

If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown on page 67 is not available in a covered facility near you, we will arrange for the transplant to be provided at an approved transplant program, if a clinical trial is available and you meet the inclusion criteria to participate in the clinical trial.

Benefits for Blood or marrow stem cell transplants are only available for the diagnoses as indicated above only when performed at a Blue Distinction Center for Transplants (see page 17) as part of a clinical trial that meets the requirements listed below:
  • You must contact us at the customer service telephone number listed on the back of your ID card to obtain prior approval (see pages 19-22); and
  • The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
  • For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board for the Blue Distinction Center for Transplant program where the procedure is to be performed.

See page 123-124 for our coverage of other costs associated with clinical trials.
 
Benefit Description

Organ/Tissue Transplants
The following transplants must be performed at a Blue Distinction Centers for Transplants (see page 17 for more information):
  • Blood or marrow stem cell transplants (adult and pediatric) listed on pages 66-67
  • Heart transplant (adult and pediatric)
    • Implantation of an artificial heart as a bridge to transplant or destination therapy (when performed in a Blue Distinction Center for Heart Transplants)
  • Liver transplant (adult and pediatric)
  • Lung:
    • For members with end-stage cystic fibrosis, benefits for lung transplantation are limited to double lung transplants
  • Pancreas transplant
  • Pancreas after kidney (adult)
  • Simultaneous liver-kidney transplant (adult)
  • Simultaneous pancreas-kidney transplant (adult)

You Pay
When performed in a Blue Distinction Centers for Transplants: 30% of the Plan allowance

All other providers (Participating/Non-participating): You pay all charges

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 the service.
 
Organ/Tissue Transplants - continued on next page