Section 5(b). Overview

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

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will find that some benefits are listed in more than one Section of the brochure. This is because how they are paid depends on what type of provider bills for the service.
The services listed in this Section are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e., hospital, surgical center, etc.).
Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a Preferred pharmacy thereafter. This benefit limitation does not apply if you have primary Medicare Part B coverage or are enrolled in the FEP Medicare Prescription Drug Program. See Section 5(f) for information about specialty drug fills from a Preferred pharmacy. Medications restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
YOU MUST GET PRIOR APPROVAL for services such as the following: surgery for severe obesity and oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures.
YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures; and if your surgical procedure requires an inpatient admission, YOU MUST GET PRECERTIFICATION. Please refer to the prior approval and precertification information shown in Section 3 to be sure which services require prior approval or precertification.
YOU MUST GET PRIOR APPROVAL for gender affirming surgery. Prior to any gender affirming surgery, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan (including changes to the procedures to be performed or the anticipated dates for the procedures). See Section 3 for additional information. If your surgical procedure requires an inpatient admission, YOU MUST ALSO GET PRECERTIFICATION of the inpatient care.
YOU MUST GET PRIOR APPROVAL FOR CERTAIN PROCEDURES; FAILURE TO DO SO WILL RESULT IN A $100 PENALTY. Please refer to Section 3 for the complete list of services which require prior approval.
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).
When unusual circumstances require the removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable.
The calendar year deductible is: $500 per person ($1,000 per Self Plus One or Self and Family enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this section.
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.