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

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Benefit Description

Surgical Procedures (cont.)

  • Benefits for gender reassignment surgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender reassignment surgery for any condition other than gender dysphoria.
  • Gender reassignment 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
    • Member must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
    • Diagnosis of gender dysphoria by a qualified healthcare professional
      • New gender identity has been present for at least 24 continuous months
      • Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
      • Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
      • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
    • Member must meet the following criteria:
      • Living 12 months of continuous, full time, real life experience in the desired gender (including place of employment, family, social and community activities)
      • 12 months of continuous hormone therapy appropriate to the member’s gender identity
      • Two referral letters from qualified mental health professionals – one must be from a psychotherapist who has treated the member for a minimum of 12 months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery
      • If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

You Pay
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Benefit Description
Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over and the procedure must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

  • Benefits are available only for the following procedures:
    • Roux-en-Y
    • Gastric bypass
    • Laparoscopic adjustable gastric banding
    • Sleeve gastrectomy
    • Biliopancreatic bypass with duodenal switch

You Pay
When performed in a Blue Distinction Center for Comprehensive Bariatric Surgery: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges

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 the service.
Surgical Procedures - continued on next page