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2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 62

Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See below and Section 3 for the exceptions to this requirement.
- We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be responsible for any difference between our payment and the billed amount. See Section 4, NSA, for information on when you are not responsible for this difference.

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

Benefit Description

Surgical Procedures
A comprehensive range of services, such as:

Operative procedures
Assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures
Treatment of fractures and dislocations, including casting
Normal pre- and post-operative care by the surgeon
Correction of amblyopia and strabismus
Colonoscopy, with or without biopsy

Note: Preventive care benefits apply to the professional charges for your first covered colonoscopy of the calendar year, see Section 5(a). We provide benefits as described here for subsequent colonoscopy procedures performed by a professional provider in the same year.
Endoscopic procedures
Injections
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies
Treatment of burns
Male circumcision
Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and Prosthetic Devices, and Section 5(c), Other Hospital Services and Supplies, for our coverage for the device.
Procedures to treat severe obesity when you meet the clinical criteria listed in our medical policy at www.fepblue.org/legal/policies-guidelines for any initial and subsequent surgery (prior approval required).

Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See Section 3 for more information.

Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.

Participating/Non-participating: You pay all charges

Surgical Procedures - continued on next page

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