2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Reconstructive Surgery

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

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)
     

 

• Gender affirming 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 (not required for mastectomy)
       
    • 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 (one referral letter required for mastectomy)
       
    • If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

Standard Option - You Pay
See above

Basic Option - You Pay
See above

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)
   
• Reversal of gender affirming surgery

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges