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medically necessaryin patients with an appropriate indication for allogeneic stem-cell transplant.

Collection and storage of cord blood from a neonate may be considered medically necessarywhen an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogeneic transplant.

Transplantation of cord blood stem cells from related or unrelated donors is considered investigationalin all other situations.

Post-Transplant Services

Benefits for post-transplant services include post-surgical care. Blue Distinction Centers for Transplant (BDCT)

Blue Distinction Centers for Transplant are a cooperative effort of the Blue Cross and/or Blue Shield Plans, the BlueCross BlueShield Association and participating medical institutions to provide patients who need transplants with access to leading transplant centers through a coordinated, streamlined program of transplant management. When a transplant is performed at a BDCT facility designated for that transplant type, certain benefitsare provided for travel, lodging, and meal expenses for the memberand one support companion. Items that are not covered expenses include, but are not limited to, alcohol, tobacco, car rental, entertainment, expenses for persons other than the memberand the member’scompanion, telephone calls, and personal care items.

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Benefitsfor surgeryinclude facility and professional services for preoperative care, surgical procedures, and post- operative care.

Evaluation & Management (E&M)

Benefits for evaluation and management related to surgeryinclude the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.

Surgical Procedure

Benefits for the surgical procedure include surgical services required for the treatment of a disease or injury when performed by a physicianor other professional provideron a memberin an inpatient hospitalor outpatient

setting. Certain rules and guidelines apply if an additional surgeon or multiple surgeries are needed. Anesthesia Related to Surgery

Benefits for the administration of anesthesia related to surgeryinclude services ordered by the attending

professional providerand rendered by a professional providerincluding the operating physician under certain circumstances, but other than the assistant at surgeryor the attending physician.

Benefitsalso include hospitalization and all related medical expenses normally incurred as a result of the administration of general anesthesia in a hospital or ambulatory surgical facility setting for non-covered dental procedures or non covered oral surgery for memberswho are seven (7) years of age or younger and memberswho are developmentally disabled, provided Capitalhas determined services to be medically necessaryand when a successful result cannot be expected for treatment under local anesthesia and for whom a superior result can be expected under general anesthesia. Anesthesia and all related benefitsfor membersseven (7) years of age or younger and memberswho are developmentally disabled are subject to all applicable cost-sharing amounts.

Mastectomy and Related Services

A mastectomy is the surgical removal of all or part of a breast. Benefitsfor a mastectomy include a mastectomy performed on an inpatientor outpatientbasis and surgeryperformed to reestablish symmetry or alleviate

functional impairment, including, but not limited to augmentation, mammoplasty, reduction mammoplasty and mastopexy. Reconstruction to reestablish symmetry is covered for the unaffected breast as well as the affected breast. Benefitsare also provided for physical complications due to the mastectomy such as lymphedema. Oral Surgery

Benefitsfor oral surgeryinclude root recovery, surgical exposure of impacted or unerupted teeth, fractures and dislocations of the face or jaw, surgical excisions (e.g., cysts, tori, exostosis), to improve function, dental implants when major disease, trauma, or surgery results in insufficient boney structure to support dentures or other oral prosthetics in order to chew, and lingual frenulum repairs.

Orthognathic surgeryis limited to conditions resulting in significant functional impairment, and repair of traumatic injuries.

Anesthesia charges associated with oral surgery are covered for memberswho are seven (7) years of age or younger and memberswho are developmentally disabled when determined by Capitalto be medically necessary

and when a successful result cannot be expected for treatment under local anesthesia and for whom a superior result can be expected under general anesthesia. Anesthesia and all related benefitsfor membersseven (7) years of age or younger and memberswho are developmentally disabled are subject to all applicable cost-sharing amounts.

Other Surgeries

Benefits for other specialized surgical procedures include:  Routine neonatal circumcisions; and

 Sterilization procedures.

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Benefits for maternity services include prenatal, delivery and postpartum services provided to a female member

for pregnancies. Prenatal Services

Benefits for prenatal services include an initial examination, tests, and a series of follow-up exams to monitor the health of the mother and fetus. Prenatal services continue up to the date of delivery.

Delivery

Benefits for deliveries include facility and professional services for vaginal and cesarean section deliveries. Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefitsfor any hospitallength of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider(e.g., physician,

Benefit Descriptions