2023 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 66

Benefit Description

Reconstructive Surgery
 

• Surgery to correct a functional defect
   
• Surgery to correct a congenital anomaly (See Section 10, page 152, 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
    
    Note: Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
    
    Note: 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

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 page 24 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: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)

Participating/Non-participating: You pay all charges

Benefit Description
 

• Gender affirming surgical benefits are limited to the following:
   
  • For female to male surgery: mastectomy (including nipple reconstruction), 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)
     

Standard Option - You Pay
See above

Basic Option - You Pay
See above

Reconstructive Surgery - continued on next page

Go to page 65. Go to page 67.