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

Page 60


Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
 
  • You must use Preferred providers in order to receive benefits. See below and page 18 for the exceptions to this requirement.
     
  • We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You are responsible for any difference between our payment and the billed amount.
 
Benefit Description

Surgical Procedures

A comprehensive range of services, such as:

 
  • Operative procedures
     
  • Assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures
     
  • Treatment of fractures and dislocations, including casting
     
  • Normal pre- and post-operative care by the surgeon
     
  • Correction of amblyopia and strabismus
     
  • Colonoscopy, with or without biopsy

    Note: Preventive care benefits apply to the professional charges for your first covered colonoscopy of the calendar year (see page 42). We provide benefits as described here for subsequent colonoscopy procedures performed by a professional provider in the same year.

     
  • Endoscopic procedures
     
  • Injections
     
  • Biopsy procedures
     
  • Removal of tumors and cysts
     
  • Correction of congenital anomalies (see Reconstructive Surgery on page 63)
  • Treatment of burns
     
  • Male circumcision
     
  • Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and Prosthetic Devices, and “Other hospital services and supplies” in Section 5(c), Inpatient Hospital, for our coverage for the device.
     
  • Gender reassignment surgical benefits are limited to the following:
     
    • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, 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, and electrolysis (hair removal at the covered operative site)
       
Notes:
 
  • Prior approval is required for gender reassignment surgery. For more information about prior approval, please refer to page 20.

You Pay
Preferred: 30% of the Plan allowance

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

 
 
Surgical Procedures - continued on next page