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 65
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 65
Benefit Description
Reconstructive Surgery (cont.)
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: 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.)
- Gender affirming surgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The member must meet all requirements.
- Prior approval is obtained
Correction, 3/13/2024 - Member must be at least 16 years of age for mastectomy and 18 years of age for other covered surgeries
genital surgeryat the time prior approval is requested and the treatment plan is submitted
- Diagnosis of gender dysphoria by a qualified healthcare professional with well-documented persistent gender incongruence, including documentation that other possible causes of gender incongruence have been excluded
- Member must meet the following criteria:
- 6 months of continuous hormone therapy appropriate to the member’s gender identity (unless medically contraindicated and they are not required for mastectomy)
Added, 3/13/2024 - Documentation of informed consent and fulfillment of the program’s criteria for gender affirming surgical treatment
- Must have a written psychological assessment from a qualified mental health professional documenting the diagnosis of persistent gender dysphoria with a well-documented persistent gender incongruence between the assigned gender and the experienced/expressed gender or some alternative gender, support of surgical procedure(s), and well-controlled physical and mental health conditions
- Surgical treatment plan must include timing, technique, and duration of aftercare
- 6 months of continuous hormone therapy appropriate to the member’s gender identity (unless medically contraindicated and they are not required for mastectomy)
- Prior approval is obtained
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: 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:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)
- Surgeries related to sexual dysfunction or sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction)
- Reversal of gender affirming surgery
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges