2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 2. Changes for 2024
Page 16
Section 2. Changes for 2024
Page 16
- For members enrolled in the FEP Medicare Prescription Drug Program, your coinsurance for Tier 3 non-preferred brand-name drugs purchased at a network pharmacy is 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply, and 40% of the Plan allowance up to a ($1,050 maximum) for each purchase of up to a 90-day supply, deductible does not apply. Previously, we did not provide this separate prescription drug program. (See page 95.)
- For members enrolled in the FEP Medicare Prescription Drug Program, your coinsurance for Tier 4 specialty drugs purchased at a network pharmacy is 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply, and 40% of the Plan allowance up to a ($1,050 maximum) for each purchase of up to a 90-day supply, deductible does not apply. Previously, we did not provide this separate prescription drug program. (See page 95.)
- We now provide coverage for marital and family counseling, Previously, we did not cover these visits. (See page 82.)
- We now provide coverage for breast augmentation for male to female gender affirming care. Previously, we did not list this as a covered service. (See page 58.)
- We now provide coverage for a mastectomy beginning at the age of 16 for female to male gender affirming care. Previously, we did not provide benefits until the age of 18. (See page 58.)
- We now require only 6 months of continuous hormone therapy appropriate to the member’s gender identity, unless medically contraindicated. Previously, we required 12 months of continuous hormone therapy. (See page 58.)
- We now cover certain facial surgeries for gender affirming care and no longer limit covered medically necessary gender affirming surgical services to once per lifetime. Previously, we did not cover facial gender affirming surgery, and we limited covered procedures to once per lifetime. (See pages 57 and 58.)
- We have reduced the number of referral letters documenting the diagnosis of gender dysphoria and other criteria to one. Previously, we required two letters. (See page 58.)
- Kidney transplants will now require prior approval, and corneal transplants are now covered under the regular surgical benefit. Previously, kidney transplants did not require prior approval. (See page 23.)
- We have added the following diagnoses and/or stages of diagnoses to the allogeneic blood or marrow stem cell transplants that do not require a clinical trial: Blastic plasmacytoid dendritic cell neoplasm; Adrenoleukodystrophy, Globoid cell leukodystrophy (Krabbe’s leukodystrophy); IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome); Dyskeratosis congenita; Hypereosinophilic syndromes; plasma cell leukemia; severe congenital neutropenia, common variable immunodeficiency, chronic granulomatous disease/phagocytic cell disorders; and Systemic mastocytosis, aggressive. Previously, we did not cover these diagnoses. (See page 61.)
- We have added the following diagnoses and/or stages of diagnoses to the autologous blood or marrow stem cell transplants that do not require a clinical trial: autoimmune – limited to idiopathic (juvenile) rheumatoid arthritis, multiple sclerosis (treatment-refractory relapsing with high risk of future disability) and scleroderma/systemic sclerosis); chronic lymphocytic leukemia (e.g., T cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia); relapsed neuroblastoma; osteosarcoma; plasma cell leukemia; and Wilms Tumor. Previously, we did not cover these diagnoses, or we required they be done as part of a clinical trial. (See pages 61-62.)
- We no longer require a clinical trial for allogeneic or autologous bone or marrow stem cell transplants with the following diagnoses: Multiple Sclerosis and Wilms Tumor.
- We no longer cover allogeneic bone or marrow stem cell transplants with the following diagnoses: colon cancer; epidermolysis bullosa; glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme); ovarian cancer; prostate cancer; or autologous bone or marrow transplants for retinoblastoma.
- For allogeneic blood or marrow stem cell transplants, we now cover additional diagnoses only when performed as part of a clinical trial: autoimmune disease (limited to scleroderma/systemic sclerosis, systemic lupus erythematosus, Idiopathic (juvenile) rheumatoid arthritis, CIDP (chronic inflammatory demyelinating polyneuropathy); Germ Cell Tumors; high-risk or relapsed neuroblastoma; lysosomal metabolic diseases: e.g., Mucopolysaccharidosis type II (Hunter syndrome), Mucopolysaccharidosis type IV (Morquio syndrome), Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome), Fabry disease, Gaucher disease. (See page 62.)
- For autologous blood or marrow stem cell transplants, we now cover additional diagnoses only when performed as part of a clinical trial: autoimmune disease (e.g., systemic lupus erythematosus, Crohn’s disease, Polymyositis-dermatomyositis, rheumatoid arthritis, CIDP (chronic inflammatory demyelinating polyneuropathy); and sarcoma (e.g., rhabdomyosarcoma, soft tissue sarcoma). Previously, we did not cover transplants for these diagnoses. (See page 62.)