2025 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 60
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 60
Organ/Tissue Transplants
Covered solid organ/tissue transplants listed below are subject to medical necessity and experimental/investigational review, and to the prior approval requirements shown below.
Prior approval requirements:
You must obtain prior approval from the Local Plan for the procedure and precertification for the facility admission (see Section 3).
In addition, benefits are only available for some transplants (and covered related services) when performed in a Blue Distinction Center or Medicare-Approved Transplant Program as described in this section. Benefits for implantation of an artificial heart as a bridge to transplant or destination therapy are only available when the facility is designated as a Blue Distinction Center for heart transplants.
Notes:
Covered solid organ/tissue transplants listed below are subject to medical necessity and experimental/investigational review, and to the prior approval requirements shown below.
Prior approval requirements:
You must obtain prior approval from the Local Plan for the procedure and precertification for the facility admission (see Section 3).
In addition, benefits are only available for some transplants (and covered related services) when performed in a Blue Distinction Center or Medicare-Approved Transplant Program as described in this section. Benefits for implantation of an artificial heart as a bridge to transplant or destination therapy are only available when the facility is designated as a Blue Distinction Center for heart transplants.
Notes:
- Organ transplants that are not available in a Blue Distinction Center for Transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. 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 Preferred facility that performs the procedure. If Medicare offers an approved program for an anticipated organ transplant, but your facility is not approved by Medicare for the procedure, please contact your Local Plan at the customer service phone number appearing on the back of your ID card.
Benefit Description
Organ/Tissue Transplants
The following transplants must be performed at a Blue Distinction Centers for Transplants (see Section 3 for more information):
Note: See the end of this section for covered related transplant services.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Organ/Tissue Transplants
The following transplants must be performed at a Blue Distinction Centers for Transplants (see Section 3 for more information):
- 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)
- 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 (adult) (single, double, or lobar) transplant - benefits are limited to double lung transplants for members with end-stage cystic fibrosis
- Combination liver-kidney transplant (adult)
Note: See the end of this section for covered related transplant services.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
The following transplants may not be available in a Blue Distinction Centers for Transplants® and must be performed at a Preferred facility with a Medicare-Approved transplant program, if one is available (see below):
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
The following transplants may not be available in a Blue Distinction Centers for Transplants® and must be performed at a Preferred facility with a Medicare-Approved transplant program, if one is available (see below):
- Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
- Heart-lung transplant
- Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
- Kidney transplant
- Pancreas transplant
- Combination liver-kidney transplant (pediatric)
- Combination pancreas-kidney transplant
- Single, double, or lobar lung transplant (pediatric)
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Organ/Tissue Transplants – continued on next page