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

Oral and Maxillofacial Surgery
Oral surgical procedures when prior approved are limited to:

 
  • Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
     
  • Surgery needed to correct accidental injuries (see Definitions, page 131) to jaws, cheeks, lips, tongue, roof and floor of mouth
     
  • Excision of exostoses of jaws and hard palate
     
  • Incision and drainage of abscesses and cellulitis
     
  • Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
     
  • Reduction of dislocations and excision of temporomandibular joints
     
  • Removal of impacted teeth

Notes:

 
  • See page 20 for information regarding prior approval.
     
  • Prior approval is required for oral/maxillofacial surgery, except when related to an accidental injury and provided within 72 hours of the accident. For more information regarding the prior approval see page 19.
     
  • Call us at the customer service telephone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., oral surgery) you are scheduled to receive.

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description
Not covered:

 
  • Oral implants and transplants except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically described above and in Section 5(g)

You Pay
All charges
 

List Item:

Oral
maxillofacial
surgery
prior
approval
approved
tumor
cysts
jaws
cheeks
lips
tongue
roof
floor
mouth
pathological
excision
extoses
jaw
palate
incision
drainage
abscesses
cellulits
sinuses
salivary
ducts
glands
dislocation
temporomandibular
joints
TMJ
impacted
teeth
face
implants
transplants
periodontal
gingiva
alveolar
bone
accidental
orthodontic