Transplant Benefits. Tissue and Kidney Transplants Benefits are provided for Hospital and professional services provided in connection with human tissue and kidney transplants when the Member is the transplant recipient. Benefits include services incident to obtaining the human transplant material from a living donor or a tissue/organ transplant “bank.” Special Transplants Benefits are provided for certain procedures, listed below, only if (1) performed at a Special Transplant Facility contracting with Blue Shield to provide the procedure, or in the case of Members accessing this Benefit outside of California, the procedure is performed at a transplant facility designated by Blue Shield, (2) prior authorization is obtained, in writing through the Benefits Management Program and (3) the recipient of the transplant is a Subscriber or Dependent. Failure to obtain prior written authorization and/or failure to have the procedure performed at a contracting Special Transplant Facility will result in denial of claims for this Benefit. The following procedures are eligible for coverage under this provision:
Transplant Benefits. (a) Medically necessary human-to-human heart transplants shall be a covered benefit under the Basic Plan. The participant must obtain prior authorization from the Utilization Review Contractor and is subject to the terms and conditions of the Pre-Admission Review Program set forth in subsection 34.1.a.(4) of this Article, above.
Transplant Benefits. Organ Transplants Benefits are provided for Hospital and professional Services provided in connection with human organ transplants, only to the extent that:
Transplant Benefits. Transplant benefits include coverage for donation- related services for a living donor (including a poten- tial donor), or a transplant organ bank. Donor ser- vices must be directly related to a covered transplant and must be prior authorized by Blue Shield. Xxxx- tion-related services include harvesting of the organ, tissue, or bone marrow and treatment of medical complications for a period of 90 days following the evaluation or harvest service.
Transplant Benefits. Transplant benefits include coverage for donation- related services for a living donor (including a po- tential donor), or a transplant organ bank. Donor services must be directly related to a covered trans- plant and must be prior authorized by Blue Shield. Donation-related services include harvesting of the organ, tissue, or bone marrow and treatment of medical complications for a period of 90 days fol- lowing the evaluation or harvest service. Tissue and Kidney Transplants Benefits are provided for Hospital and profes- sional services provided in connection with human tissue and kidney transplants when the Member is the transplant recipient. Benefits include services incident to obtaining the human transplant material from a living donor or a tissue/organ transplant bank. Special Transplants Benefits are provided for certain procedures, listed below, only if: (1) performed at a Special Trans- plant Facility contracting with Blue Shield to pro- vide the procedure, or in the case of Members ac- cessing this Benefit outside of California, the pro- cedure is performed at a transplant facility desig- nated by Blue Shield, (2) prior authorization is ob- tained, in writing through the Benefits Manage- ment Program and (3) the recipient of the trans- plant is a Subscriber or Dependent. Benefits in- clude services incident to obtaining the human transplant material from a living donor or an organ transplant bank. Failure to obtain prior written authorization and/or failure to have the procedure performed at a con- tracting Special Transplant Facility will result in denial of claims for this Benefit. The following procedures are eligible for coverage under this provision:
Transplant Benefits. Special 34 Note: Blue Shield requires prior authorization from Blue Shield's Medical Xx- xxxxxx for all Special Transplant Services. Also, all Services must be provided at a Special Transplant Facility designated by Blue Shield. Please see the Transplant Benefits portion of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this benefit. Facility Services in a Special Transplant Facility $250 per admission plus 30% Not covered Professional (Physician) Services 30% Not covered
Transplant Benefits. Special Blue Shield requires prior authorization for all Special Transplant Services, and all services must be provided at a Special Transplant Facility designated by Blue Shield. See the Transplant Benefits – Special Transplants section of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this Benefit. Facility services in a Special Transplant Facility 10% Not covered Professional (Physician) services 10% Not covered Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Pediatric Vision Benefits 25 Pediatric vision benefits are available for members through the end of the month in which the member turns 19. All Services provided through Blue Shield’s Vision Plan Administrator (VPA). Comprehensive examination 21 One comprehensive eye examination per Calendar Year. Includes dilation, if professionally indicated. Ophthalmologic New Patient (S0620) Established Patient (S0621) You pay nothing Up to $30 Optometric New Patient (92002/92004) Established Patient (92012/92014) You pay nothing Up to $30 Eyewear/materials One pair of eyeglasses (frames and lenses) or one pair of contact lenses per Calendar Year (unless otherwise noted) as follows: Lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglass. Polycarbonate lenses are covered in full for eligible Members. Single Vision (V2100-V2199) You pay nothing Up to $25 Lined Bifocal (V2200-V2299) You pay nothing Up to $35 Lined Trifocal (V2300-V2399) You pay nothing Up to $45 Lenticular (V2121, V2221, V2321) You pay nothing Up to $45 Optional Lenses and Treatments Ultraviolet Protective Coating (standard only) You pay nothing Not covered Standard Progressive Lenses $55 Not covered Premium Progressive Lenses $95 Not covered Anti-Reflective Lens Coating (standard only) $35 Not covered Photochromic- Glass Lenses $25 Not covered Photochromic- Plastic Lenses $25 Not covered Hi Index Lenses $30 Not covered Polarized Lenses $45 Not covered Frames 23 Collection frames You pay nothing Up to $40 Non-Collection frames Up to $150 Up to $40 Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Contact Lenses 24 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothi...
Transplant Benefits. Once it has been determined that a Member may require a Transplant, the Member or the Member’s Physician must call the Member Services number on the Member’s identification card to discuss entrance into the National Medical Excellence Program. Non-experimental or non-investigational Transplants coordinated through the National Medical Excellence Program and performed at an Institute of Excellence, (IOE), are Covered Benefits. The IOE facility must be specifically approved and designated by HMO to perform the Transplant required by the Member. Covered Benefits include the following when provided by an IOE: • Inpatient and outpatient expenses directly related to a Transplant. • Charges for Transplant-related services, including pre-Transplant evaluations, testing and post- Transplant follow-up care. • Charges made by an IOE Physician or Transplant team. • Compatibility testing of prospective organ donors who are immediate family members. • Charges for activating the donor search process with national registries. • Charges made by a Hospital and/or Physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. • Related supplies and services provided by the IOE facility during the Transplant process. These services and supplies may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants; Home Health Services and home infusion services.
Transplant Benefits. Transplants which are non-experimental or non-investigational are a Covered Benefit. Transplants which are Experimental or Investigational may be covered if approved in advance by HMO. For additional information about the criteria and process for approval of Experimental and Investigational transplants call member Services at 0-000-000-0000. The Complaints and Appeals and Independent Medical Review sections of this EOC provide additional information regarding the Member’s right to appeal and Independent Medical Review of HMO decisions that a proposed transplant is Experimental or Investigational. Once it has been determined that a Member may require a Transplant, the Member or the Member’s Physician must call the HMO precertification department to discuss coordination of the Transplant process. Non-experimental or non-investigational Transplants coordinated by HMO and performed at an Institute of Excellence, (IOE), are Covered Benefits. The IOE facility must be specifically approved and designated by HMO to perform the Transplant required by the Member. Covered Benefits include the following when provided by an IOE. • Inpatient and outpatient expenses directly related to a Transplant Occurrence. • Charges made by a Physician or Transplant team. • Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an “immediate” family member is defined as a first-degree biological relative. These are your biological parent, sibling or child. • Charges for activating the donor search process with national registries. • Charges made by a Hospital or outpatient facility and/or Physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. • Related supplies and services provided by the IOE facility during the Transplant Occurrence process. These services and supplies may include: physical, speech and occupational therapy; bio- medicals and immunosuppressants; Home Health Services and home infusion services. Any Copayments associated with Transplants are set forth in the Schedule of Benefits. Copayments apply per Transplant Occurrence. One Transplant Occurrence includes the following four phases of Transplant care:
Transplant Benefits. Tissue and Kidney Transplants Benefits are provided for Hospital and professional services provided in connection with human tissue and kidney transplants when the Member is the transplant recipient. Benefits include services incident to obtaining the human transplant material from a living donor or a tissue/organ transplant “bank.” Special Transplants Benefits are provided for certain procedures, listed below, only if (1) performed at a Special Transplant Facility contracting with Blue Shield to provide the procedure, or in the case of Members accessing this Benefit outside of California, the procedure is performed at a transplant facility designated by Blue Shield, (2) prior authorization is obtained, in writing through the Benefits Management Program and (3) the
