2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 22
Section 3. How You Get Care
Page 22
- Pulmonary rehabilitation
- Radiology, high technology including:
- Magnetic resonance imaging (MRI)
- Computed tomography (CT) scan
- Positron emission tomography (PET) scan
Note: High technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval.
- Magnetic resonance imaging (MRI)
- Specialty durable medical equipment (DME), rental or purchase, to include:
- Specialty hospital beds
- Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies
- Specialty hospital beds
- Transplants: Prior Approval is required for all transplants. Prior approval is required for both the procedure and if benefits require, the transplant program; precertification is required for inpatient care.
- Blood or marrow stem cell transplants listed in Section 5(b) must be performed in a transplant program designated as a Blue Distinction Center for Transplants. Read earlier in this section for more information about these types of programs.
Not every transplant program provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the transplant program is specifically designated as a Blue Distinction Center for Transplants for that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number appearing on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
- Clinical trials for certain blood or marrow stem cell transplants – in Section 5(b) we provide a list of conditions covered only in clinical trials.
- Contact us at the customer service phone number on the back of your ID card for information or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage determination.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a Blue Distinction Center for Transplants to treat your condition. If your physician has recommended you receive a transplant or that you participate in a transplant clinical trial, we encourage you to contact the Case Management Department at your Local Plan.
Note: For the purposes of the blood or marrow stem cell clinical trial transplants covered under this Plan, a clinical trial is a research study whose protocol has been reviewed and approved by the Institutional Review Board (IRB) of the Blue Distinction Center for Transplants where the procedure is to be performed.
Note: For the purposes of the blood or marrow stem cell clinical trial transplants covered under this Plan, a clinical trial is a research study whose protocol has been reviewed and approved by the Institutional Review Board (IRB) of the Blue Distinction Center for Transplants where the procedure is to be performed.
- Organ/tissue transplants
Benefits for certain transplants are limited to designated transplant centers or programs.
Some transplants listed in Section 5(b) must be performed in a transplant program designated as a Blue Distinction Center for Transplants.
Some organ transplants are not available in a Blue Distinction Center for Transplants and must be performed at a Preferred facility with a Medicare-Approved Transplant Program, if one is available.