2024 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 61
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 61
Benefit Description
Organ/Tissue Transplants (cont.)
The blood or marrow stem cell transplants (adult and pediatric) listed below and on the following pages must be performed at a Blue Distinction Center for Transplants. You must obtain prior approval from the Local Plan for the procedure and precertification for the facility admission. See Section 3 (How You Get Care). Benefits are limited to the diagnoses and stages listed.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Organ/Tissue Transplants (cont.)
The blood or marrow stem cell transplants (adult and pediatric) listed below and on the following pages must be performed at a Blue Distinction Center for Transplants. You must obtain prior approval from the Local Plan for the procedure and precertification for the facility admission. See Section 3 (How You Get Care). Benefits are limited to the diagnoses and stages listed.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefits for Allogeneic blood or marrow stem cell transplants are only available for the diagnoses indicated below:
Benefits for Autologous blood or marrow stem cell transplants are only available for the diagnoses indicated below:
- Acute lymphocytic or myeloid (e.g., AML promyelocytic) leukemia
- Blastic plasmacytoid dendritic cell neoplasm
- Chronic lymphocytic leukemia (e.g., T cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia)
- Chronic myeloid leukemia
- Hemoglobinopathy (e., sickle cell anemia, thalassemia)
- Hodgkin lymphoma
- Inherited metabolic disorders: Adrenoleukodystrophy, Globoid cell leukodystrophy (Krabbe's leukodystrophy), Metachromatic leukodystrophy, and Mucopolysaccharidosis type I (Hurler syndrome)
- IPEX - immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome
- Marrow failure (e.g., severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure red cell aplasia, congenital thrombocytopenia, Dyskeratosis congenita)
- MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))
- Myelodysplastic syndromes (MDS)
- Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis, Hypereosinophilic syndromes)
- Non-Hodgkin lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Osteopetrosis
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, plasma cell leukemia, POEMS – (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome)
- Primary immunodeficiencies (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, hemophagocytic disorders, X-linked lymphoproliferative syndrome, severe congenital neutropenia, leukocyte adhesion deficiencies, common variable immunodeficiency, chronic granulomatous disease/phagocytic cell disorders)
- Systemic mastocytosis, aggressive
Benefits for Autologous blood or marrow stem cell transplants are only available for the diagnoses indicated below:
- Acute myeloid leukemia
- Autoimmune - limited to: Idiopathic (juvenile) rheumatoid arthritis, multiple sclerosis (treatment-refractory relapsing with high risk of future disability) and Scleroderma/systemic sclerosis
- Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors (PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)
- Chronic lymphocytic leukemia (e.g., T cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia)
- Ewing sarcoma
- Germ cell tumors (e.g., testicular germ cell tumors)
- High-risk or relapsed neuroblastoma