2023 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 60
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 60
Benefit Description
Reconstructive Surgery (cont.)
Notes:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Reconstructive Surgery (cont.)
- Gender affirmingsurgical 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)
- 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
Notes:
- Prior approval is required for gender affirmingsurgery. For more information about prior approval, please refer to page 20.
- Benefits for gender affirmingsurgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender affirmingsurgery for any condition other than gender dysphoria.
- Gender affirmingsurgery 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
- New gender identity has been present for at least 24 continuous months
- 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
- Living 12 months of continuous, full time, real life experience in the desired gender (including place of employment, family, social and community activities)
- Prior approval is obtained
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges