2020 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


Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
 
Benefit Description

Reconstructive Surgery
Reconstructive surgical procedures, limited to:

 
  • Surgery to correct a functional defect
     
  • Surgery to correct a congenital anomaly (See Section 10, page 132, 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.
         
  • Surgery for placement of penile prostheses to treat erectile dysfunction

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description
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 and gender reassignment surgeries specifically listed as covered)
     
  • Reversal of gender reassignment surgery

You Pay
All charges
 

List Item:

reconstructive
surgery
correct
congenital
mouth
pre-cancer
breast
mastectomy
symmetrical
pymphedemas
prosthesis
orthopedic
prostheses
prosthetic
dysfunction
cosmetic
inadequacy
reversal
reassigment