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
Organ/Tissue Transplants
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Organ/Tissue Transplants
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
Organ/Tissue Transplants (cont.)
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
Organ/Tissue Transplants (cont.)
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
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:
Benefits for Blood or marrow stem cell transplants are available for the diagnoses below, only when performed as part of a clinical trial when a clinical trial for the diagnosis below is available in a Blue Distinction Center; and you meet the criteria for inclusion in the clinical trial and the requirements below.
Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.
A transplant clinical trial may not be available for your condition, or 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 at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the contact us at the phone number on the back of your ID card for assistance in determining if a covered clinical trial is available in a covered facility.
- 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
- Hodgkin lymphoma
- Non-Hodgkin lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Osteosarcoma
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, plasma cell leukemia, POEMS - polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome)
- Wilms Tumor
Benefits for Blood or marrow stem cell transplants are available for the diagnoses below, only when performed as part of a clinical trial when a clinical trial for the diagnosis below is available in a Blue Distinction Center; and you meet the criteria for inclusion in the clinical trial and the requirements below.
- Allogeneic blood or marrow stem cell transplants for:
- Autoimmune - limited to: scleroderma/systemic sclerosis, systemic lupus erythematosus, CIDP – (chronic inflammatory demyelinating polyneuropathy), and Idiopathic (Juvenile) rheumatoid arthritis
- Breast cancer
- 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
- Renal cell carcinoma
- Sarcoma – Ewing sarcoma, rhabdomyosarcoma, soft tissue sarcoma
- Autologous blood or marrow stem cell transplants for:
- Autoimmune disease - e.g., systemic lupus erythematosus, CIDP (chronic inflammatory demyelinating polyneuropathy), Crohn's disease, Polymyositis-dermatomyositis, rheumatoid arthritis
- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
- Sarcoma (e.g., rhabdomyosarcoma, soft tissue sarcoma
- You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see Section 3); 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.
Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.
A transplant clinical trial may not be available for your condition, or 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 at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the contact us at the phone number on the back of your ID card for assistance in determining if a covered clinical trial is available in a covered facility.
Benefit Description
Related transplant services:
Note: See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Related transplant services:
- Extraction or reinfusion of blood or marrow stem cells as part of a covered allogeneic or autologous transplant
- Harvesting, immediate preservation, and storage of stem cells when the autologous blood or marrow stem cell transplant has been scheduled or is anticipated to be scheduled within an appropriate time frame for patients diagnosed at the time of harvesting with one of the conditions previously listed
Note: Benefits are available for charges related to fees for storage of harvested autologous blood or marrow stem cells related to a covered autologous stem cell transplant that has been scheduled or is anticipated to be scheduled within an appropriate time frame. No benefits are available for any charges related to fees for long-term storage of stem cells.
- Collection, processing, storage and distribution of cord blood only when provided as part of a blood or marrow stem cell transplant scheduled or anticipated to be scheduled within an appropriate time frame for patients diagnosed with one of the conditions previously listed
- Covered medical and hospital expenses of the donor, when we cover the recipient
- Covered services or supplies provided to the recipient
- Donor screening tests for non-full sibling (such as unrelated) potential donors, for any full sibling potential donors, and for the actual donor used for transplant
Note: See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Travel benefits:
Members who receive covered care at a Blue Distinction Center for Transplants for one of the transplants listed can be reimbursed for incurred travel costs related to the transplant, subject to the criteria and limitations described here.
You must obtain prior approval for travel benefits (see Section 3).
You Pay
We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant for the member and companions. Reimbursement is subject to IRS regulations.
Travel benefits:
Members who receive covered care at a Blue Distinction Center for Transplants for one of the transplants listed can be reimbursed for incurred travel costs related to the transplant, subject to the criteria and limitations described here.
You must obtain prior approval for travel benefits (see Section 3).
You Pay
We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant for the member and companions. Reimbursement is subject to IRS regulations.
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Any transplant not listed as covered and transplants for any diagnosis not listed as covered
- Transplants performed in a facility other than the type of facility required for the particular transplant
- Donor screening tests and donor search expenses, including associated travel expenses, except as defined above
- Implants of artificial organs, including those implanted as a bridge to transplant and/or as destination therapy, other than medically necessary implantation of an artificial heart as previously described
- Implantation of an artificial heart in a facility not designated as a Blue Distinction Center for Heart Transplant
- Allogeneic pancreas islet cell transplantation
- Travel costs related to covered transplants performed at facilities other than Blue Distinction Centers for Transplants; travel costs incurred when prior approval has not been obtained; travel costs outside those allowed by IRS regulations, such as food-related expenses
You Pay
All charges