Organ and Tissue Transplants
Organ and tissue transplants are covered at 70% after the deductible has been met and when pre-authorized by Anthem Blue Cross. (Medicare-eligible members do not need pre-authorization by Anthem Blue Cross.) Transplant services received from an Anthem Blue Cross Center of Expertise (COE) facility or a network provider are based on the negotiated rates. Transplant services received from a non-network provider are based on the Customary and Reasonable Charges (see "Eligible Expenses" under the Definitions section for the Anthem Blue Cross-Administered Plans). Pre-authorization is required for all transplant services.
Benefits are available for the following organ and tissue transplants when the transplant is ordered by a physician, meets the definition of a Covered Health Service and is not an unproven, experimental, or investigational service, as described under "What the ROP Does Not Cover."
  • Bone marrow transplants (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy. Not all bone marrow transplants meet the definition of a Covered Health Service.
  • Heart transplants
  • Heart/lung transplants
  • Lung transplants
  • Liver transplants
  • Kidney transplants
  • Kidney/pancreas transplants
  • Liver/small bowel transplants
  • Pancreas transplants
  • Small bowel transplants
  • Cornea transplants
Organ or tissue transplants or multiple organ transplants, other than those listed above, are currently excluded from coverage.
Centers of Medical Excellence (CME) Transplant Facilities
In California, Anthem Blue Cross has established a Centers of Medical Excellence (CME) network of transplant facilities to provide services for specified organ transplants (heart, liver, lung, heart-lung, kidney-pancreas, or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and similar procedures). Equivalent approved transplant facilities are located outside of California.
CMEs are health care providers designated by Anthem Blue Cross as selected facilities for specified medical services. A provider participating in a CME network has a CME Agreement in effect with Anthem Blue Cross at the time services are rendered or is available through their affiliate companies or their relationship with the Blue Cross and Blue Shield Association. CMEs agree to accept the CME negotiated rate as payment in full for covered services. A participating provider in the Anthem Blue Cross PPO network is not necessarily a CME. A provider's participation in the Anthem Blue Cross PPO network or other agreement with Anthem Blue Cross is not a substitute for a CME Agreement.
Obtain Authorization from Anthem Blue Cross' Authorization Program
Authorization is required for all transplant services. You must call the Pre-Authorization and Pre-Service toll-free number at 800-274-7767as soon as the possibility of a transplant arises. The Authorization Program will arrange for a pre-transplantation evaluation to be performed at a CME transplant facility. The Authorization Program also can discuss your benefit options and any special transplant guidelines.
Travel Expenses
You may be eligible to receive reimbursement for some or all of your travel expenses associated with undergoing an organ transplant. For more information, see "Transportation and Lodging."