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Georgia Health Insurance Benefits Information

Oral Surgery
Pre-certification is required and must be obtained by the Participant from a Network Physician. Covered Services include only the following:

• Fracture of facial bones;
• Lesions of the mouth, lip, or tongue which require a pathological exam;
• Incision of accessory sinuses, mouth salivary glands or ducts;
• Dislocations of the jaw;
• Removal of impacted teeth and associated hospitalization. Pre-certification is required and must be obtained by the Participant from a Network Physician;
• Treatment of Temporomandibular Joint Syndrome (TMJ) or myofacial pain including only removable appliances for TMJ repositioning and related surgery and diagnostic services. Covered Services do not include fixed or removable appliances which involve movement or repositioning of the teeth, or operative restoration of teeth (fillings), or prosthetics (crowns, bridges, dentures);
• Orthognathis surgery (based on Medical Necessity);
• Plastic repair of the mouth or lip necessary to correct traumatic injuries or congenital defects that will lead to functional impairments; and
• Initial services, supplies or appliances for dental care or treatment required as a result of, and directly related to, accidental bodily Injury to sound natural teeth or structure occurring while a Participant is covered by this Plan and performed within 180 days after the accident.

Organ/Tissue/Bone Marrow Transplant
Covered Services include certain services and supplies not otherwise excluded in this SPD Booklet and rendered in association with a covered transplant, including pre-transplant procedures such as organ harvesting (donor costs), post-operative care (including antirejection drug treatment, if Prescription Drugs are covered under the Plan) and transplant related chemotherapy for cancer limited as follows.

A transplant means a procedure or series of procedures by which an organ or tissue is either:

• removed from the body of one person (called a "donor") and implanted in the body of another person (called a "recipient"); or
• removed from and replaced in the same person's body (called a "self-donor").

A covered transplant means a medically appropriate transplant of one of the following organs or tissues only and no others.

• Human organ or tissue transplants for cornea, lung, heart or heart/lung, liver, kidney, pancreas or kidney and pancreas when transplanted together in the same operative session.
• Autologous (self-donor) bone marrow transplants with high-dose chemotherapy are considered eligible for coverage on a prior approval basis, but only if required in the treatment of :
• • Non-Hodgkin's lymphoma, intermediate or high grade Stage III or IVB;
  • Hodgkin's disease (lymphoma), Stages IIIA, IIIB, IVA, or IVB;
  • Neuroblastoma, Stage III or Stage IV;
  • Acute lymphocytic or nonlymphocytic leukemia patients in first or subsequent remission, who are at high risk for relapse and who do not have HLA-compatible donor available for allogenic bone marrow support;
  • Germ cell tumors (e.g., testicular, mediastinal, retroperitoneal, ovarian) that are refractory to standard dose chemotherapy, with FDA-approved platinum compounds;
  • Metastatic breast cancer that (a) has not been previously treated with systemic therapy, (b) is currently responsive to primary systemic therapy, or (c) has relapsed following response to first-line treatment;
  • Newly diagnosed or responsive multiple myeloma, previously untreated disease, those in a complete or partial remission, or those in a responsive relapse.
• Homogenic/allogenic (other donor) or syngeneic hematopoietic stem cells whether harvested from bone marrow peripheral blood or from any other source, but only if required in the treatment of:
• aplastic anemia;
• acute leukemia;
• severe combined immunodeficiency exclusive of acquired immune deficiency syndrome (AIDS);
• infantile malignant osteoporosis;
• chronic myelogenous leukemia;
• lymphoma (Wiscott-Aldrich syndrome);
• lysosomal storage disorder;
• myelodysplastic syndrome.

"Donor Costs" means all costs, direct and indirect (including program administration costs), incurred in connection with:

• medical services required to remove the organ or tissue from either the donor's or the self- donor's body;
• preserving it;
• transporting it to the site where the transplant is performed; and
• we do not cover health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person (donor costs for removal are payable for a transplant through the organ recipient's benefits under the plan).

In treatment of cancer, the term "transplant" includes any chemotherapy and related courses of treatment which the transplant supports.

For purposes of this benefit, the term "transplant" does not include transplant of blood or blood derivatives (except hematopoietic stem cells) which will be considered as non-transplant related under the terms of the Plan.

"Facility Transplant" means all Medically Necessary services and supplies provided by a health care facility in connection with a covered transplant except donor costs and antirejection drugs.

"Medically Appropriate" means the recipient or self-donor meets the criteria for a transplant established by the Plan.

"Professional Provider Transplant Services" means all Medically Necessary services and supplies provided by a professional provider in connection with a covered transplant except donor costs and antirejection drugs.

Benefits for Antirejection Drugs
For antirejection drugs following the covered transplant, the Plan will pay according to the benefits for Prescription Drugs, if any, under the Plan.

Pre-certification Requirement
All transplant procedures must be pre-certified for the type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by the Claims Administrator. To pre-certify, call the Claims Administrator's office using the telephone number on your Identification Card.

The pre-certification requirements are a part of the benefit administration of the Plan and are not a treatment recommendation. The actual course of medical treatment the Participant chooses remains strictly a matter between the Participant and his or her Physician.

Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at a recognized transplant center. The donor, donor recipient and the transplant surgery must meet required medical selection criteria as defined by the Claims Administrator.

If the transplant involves a living donor, benefits are as follows:

• If a Participant receives a transplant and the donor is also covered under this Plan, payment for the Participant and the donor will be made under each individual's coverage.
• If the donor is not covered under this Plan, payment for the Participant and the donor will be made under this Plan but will be limited by any payment which might be made under any other hospitalization coverage plan.

Please see the Exclusions section for Non-Covered Services.

Osteoporosis
Benefits will be provided for qualified individuals for reimbursement for scientifically proven bone mass measurement (bone density testing) for the prevention, diagnosis and treatment of osteoporosis for Participants meeting BCBSHP's criteria.

Other Covered Services
Your Plan provides Covered Services when the following services are Medically Necessary:

• Chemotherapy and Radioisotope, Radiation and Nuclear Medicine Therapy
• Diagnostic X-ray and Laboratory Procedures
• Dressings, Splints, Casts when provided by a covered Physician
• Oxygen, Blood and Components, and Administration
• Use of Operating and Treatment Rooms and Equipment

Out-of-Area Urgent Care
Covered Services required in order to prevent serious deterioration of a Participant's health that results from an unforeseen illness or Injury if the Participant is temporarily absent from the BCBSHP Service Area and receipt of the health care service cannot be delayed until the Participant's return to the Service Area.

Ovarian Cancer Surveillance Tests
Covered Services are provided for at risk women 35 years of age and older. At risk women are defined as: (a) having a family history (i) with one or more first or second-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer, (iii) of nonpolysis colorectal cancer; or (b) testing positive for BRCA1 or BRCA2 mutations.

Surveillance tests means annual screening using: (a) CA-125 serum tumor marker testing, (b) transvaginal ultrasound, and (c) pelvic examinations.