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

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 in our medical policy at www.fepblue.org/legal/policies-guidelines for any initial and subsequent surgery (prior approval required).

Note: When multiple surgical procedures that add time or complexity to patient care are performed during the same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the primary procedure.

Note: We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).

Note: 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.


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

Benefit Description

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

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges