2025 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 64
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 64
Benefit Description
Reconstructive Surgery (cont.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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.
Participating/Non-participating: You pay all charges
Reconstructive Surgery (cont.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
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.
Participating/Non-participating: You pay all charges
Benefit Description
Note: Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.
Note: Benefits are not available for repeat or revision procedures unless they are determined to be medically necessary. Benefits are not available for gender affirming surgery for any condition other than gender dysphoria.
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 Section 3 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: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
- Gender affirming surgical benefits are limited to the following:
- Breast augmentation, clitoroplasty, electrolysis (hair removal at any covered operative site), facial surgery (limited to Adam's apple enhancement/reduction, botulinum toxin, cheek reshaping, chin reshaping, cosmetic fillers, face lift, fat grafting, forehead reshaping, hair transplant, jaw reshaping, liposuction, and rhinoplasty), voice surgery (pitch lowering or raising surgery/Wendler glottoplasty), hysterectomy, labiaplasty, mastectomy (including nipple reconstruction and suction-assisted chest lipectomy), metoidioplasty, orchiectomy, penectomy, phalloplasty, salpingo-oophorectomy, scrotoplasty, testicular and erectile prosthesis placement, urethroplasty, vaginectomy, vaginoplasty
Note: Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.
Note: Benefits are not available for repeat or revision procedures unless they are determined to be medically necessary. Benefits are not available for gender affirming surgery for any condition other than gender dysphoria.
- 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 16 years of age for mastectomy and 18 years of age for other covered surgeries at the time prior approval is requested and the treatment plan is submitted
- Prior approval is obtained
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 Section 3 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: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
Reconstructive Surgery - continued on next page