Transplant Benefits Sample Clauses

Transplant Benefits. Tissue and Kidney Transplants Special Transplants

Transplant Benefits. (a) Medically necessary human-to-human heart transplants shall be added as 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 Utilization Review Case Management Program set forth in subsection 1.a.(5) of this Article, above. (b) The aggregate lifetime maximum benefit limit per participant for all organ or tissue transplant services for all covered transplant procedures is $250,000. This aggregate lifetime maximum benefit limit applies to all benefits arising out of an organ or tissue transplant.

Transplant Benefits. Organ Transplants

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. 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. 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 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 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 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Standard sof...

Transplant Benefits. Medically necessary human to human heart transplants shall be added as a covered benefit under the Basic Plan. The participant must obtain prior authorization from the Pre-Admission Review Contractor and is subject to the terms and conditions of the Pre-Admission Review Program set forth in subsection 1.a.(5) of this Article, above.

Transplant Benefits. The Plan will cover Medically Necessary charges incurred for the care and treatment due to a solid organ, stem cell, bone marrow or tissue transplant, which are not considered Experimental or Investigational. The plan covers:  Charges made by a physician or transplant team.  Charges made by a hospital, outpatient facility 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 facility during the transplant process. These services and supplies may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants; home health care expenses and home infusion services.  Charges for activating the donor search process with national registries.  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 parents, siblings or children.  Inpatient and outpatient expenses directly related to a transplant. The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are:  Pre-transplant evaluation/screening: Includes all transplant-related professional and technical components required for assessment, evaluation and acceptance into a transplant facility’s transplant program;  Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of prospective organ donors who are immediate family members;  Transplant event: Includes inpatient and outpatient services for all covered transplant-related health services and supplies provided to you and a donor during the one or more surgical procedures or medical therapies for a transplant; prescription drugs provided during your inpatient stay or outpatient visit(s), including bio-medical and immunosuppressant drugs; physical, speech or occupational therapy provided during your inpatient stay or outpatient visit(s); cadaveric and live donor organ procurement; and  Follow-up care: Includes all covered transplant expenses; home health care services; home infusion services; and transplant-related outpatient services rendered within 180 days from the date of the transplant event. Unless specified above, not covered under this benefit are charges incurred for:  Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpat...

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- • Charges made by an IOE Physician or Transplant team. • 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.