2025 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 56

 

  • You must use Preferred providers in order to receive benefits. See below and Section 3 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, neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be responsible for any difference between our payment and the billed amount. See Section 4, NSA, for information on when you are not responsible for this difference.

 

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

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
     
  • Corneal transplant
     
  • 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 Section 5(a)). 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 
     
  • 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.
     
  • Procedures to treat severe obesity when you meet the clinical criteria listed in our medical policy at www.fepblue.org/legal/policies-guidelines for any initial and subsequent surgery (prior approval required).
Notes:
  • Surgical services to treat severe obesity must be performed in a Blue Distinction Center for Comprehensive Bariatric Surgery.
     
  • When multiple surgical procedures that add time or complexity to patient care are performed during the same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the primary procedure.
     
  • We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).


You Pay
Preferred: 30% of the Plan allowance (deductible applies)

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

 

Surgical Procedures - continued on next page

 

Go to page 55. Go to page 57.