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 64
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 64
Benefit Description
Reconstructive Surgery (cont.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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
Reconstructive Surgery (cont.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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
Note: Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.
Note: Benefits are not available for repeat or revision procedures unless they are determined to be medically necessary. Benefits are not available for gender affirming surgery for any condition other than gender dysphoria.
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.
Correction, 3/13/2024
Note: If you receive 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 surgeon.
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
- Gender affirming surgical benefits are limited to the following:
- For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, facial gender affirming surgery (limited to forehead lengthening, cheek augmentation, rhinoplasty, jaw reshaping, chin contouring, Adam’s apple enhancement (thyroid cartilage enhancement or implant), pitch lowering masculinization voice surgery, cosmetic fillers, botulinum toxin, fat grafting, and liposuction), electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
- For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, breast augmentation, facial gender affirming surgery (limited to chondrolaryngoplasty, rhinoplasty, contouring or augmentation of the jaw, chin, and forehead; facelift, hair removal and transplantation, pitch raising surgery/Wendler glottoplasty, cosmetic fillers, botulinum toxin, fat grafting and liposuction), and electrolysis (hair removal at the covered operative site)
- For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, facial gender affirming surgery (limited to forehead lengthening, cheek augmentation, rhinoplasty, jaw reshaping, chin contouring, Adam’s apple enhancement (thyroid cartilage enhancement or implant), pitch lowering masculinization voice surgery, cosmetic fillers, botulinum toxin, fat grafting, and liposuction), electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
Note: Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.
Note: Benefits are not available for repeat or revision procedures unless they are determined to be medically necessary. Benefits are not available for gender affirming surgery for any condition other than gender dysphoria.
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.
Correction, 3/13/2024
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
Reconstructive Surgery - continued on next page