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 56
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 56
Benefit Description
Surgical Procedures (cont.)
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Surgical Procedures (cont.)
- When unusual circumstances require the removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable
- For surgical family planning procedures, see Family Planning in Section 5(a).
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:
- Reversal of voluntary sterilization
- Services of a standby physician
- Routine surgical treatment of conditions of the foot (See Section 5(a), Foot care.)
- Cosmetic surgery
- LASIK, INTACS, radial keratotomy, and other refractive surgery
- Surgeries related to sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction and gender affirming surgeries specifically listed as covered)
- Reversal of gender affirming surgery
- Surgical procedures for the treatment of severe obesity when performed outside a Blue Distinction Center
You Pay
All charges
Benefit Description
Reconstructive Surgery
Reconstructive surgical procedures, limited to:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Reconstructive Surgery
Reconstructive surgical procedures, limited to:
- Surgery to correct a functional defect
- Surgery to correct a congenital anomaly (See Section 10 for definition)
- Treatment to restore the mouth to a pre-cancer state
- All stages of breast reconstruction surgery following a mastectomy, such as:
- Surgery to produce a symmetrical appearance of the patient’s breasts
- Treatment of any physical complications, such as lymphedemas
Notes:
- Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
- If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
- Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
- Surgery to produce a symmetrical appearance of the patient’s breasts
- Surgery for placement of penile prostheses to treat erectile dysfunction
- Gender affirming surgical benefits are limited to the following:
- Breast augmentation, clitoroplasty, electrolysis (hair removal at any covered operative site), facial surgery (limited to Adam's apple enhancement/reduction, botulinum toxin, cheek reshaping, chin reshaping, cosmetic fillers, face lift, fat grafting, forehead reshaping, hair transplant, jaw reshaping, liposuction, and rhinoplasty), voice surgery (pitch lowering or raising surgery/Wendler glottoplasty), hysterectomy, labiaplasty, mastectomy (including nipple reconstruction and suction-assisted chest lipectomy), metoidioplasty, orchiectomy, penectomy, phalloplasty, salpingo-oophorectomy, scrotoplasty, testicular and erectile prosthesis placement, urethroplasty, vaginectomy, vaginoplasty
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Reconstructive Surgery - continued on next page