2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 58
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 58
Benefit Description
Oral and Maxillofacial Surgery
Oral surgical procedures when prior approved are limited to:
Notes:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Oral and Maxillofacial Surgery
Oral surgical procedures when prior approved are limited to:
- Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
- Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth
- Excision of exostoses of jaws and hard palate
- Incision and drainage of abscesses and cellulitis
- Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
- Reduction of dislocations and excision of temporomandibular joints
- Removal of impacted teeth
Notes:
- See Section 3 for information regarding prior approval.
- Prior approval is required for oral/maxillofacial surgery, except when related to an accidental injury and provided within 72 hours of the accident. For more information regarding the prior approval see Section 3.
- Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., oral surgery) you are scheduled to receive.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Oral implants and transplants except for those required to treat accidental injuries as specifically described above and in Section 5(g)
- Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically described above and in Section 5(g)
- Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically described above and in Section 5(g)
- Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically described above and in Section 5(g)
You Pay
All charges