MMC Benefits Handbook
Gene Therapy Services
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
Your Plan includes benefits for gene therapy services, when Anthem approves the benefits in advance through Precertification. To be eligible for coverage, services must be Medically Necessary and performed by an approved Provider at an approved treatment center. Even if a Provider is a Network Provider for other services they may not be an approved Provider for certain gene therapy services. Please call the Claims Administrator to find out which providers are approved Providers. When calling Member Services, ask for the transplant case manager for further details.
Services Not Eligible for Coverage
Your Plan does not include benefits for the following:
  • Services determined to be Experimental/Investigational;
  • Services provided by a non-approved Provider or at a non-approved Facility; or
  • Services not approved in advance through Precertification.