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This brochure version is for internal use only.

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 57

You must use Preferred providers in order to receive benefits. See below and page 18 or 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 page 29, 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
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 page 42). 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 (see Reconstructive Surgery on page 59)
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.

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

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

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

Benefit Description

Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 16 or over and the procedure must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

Benefits are available only for the following procedures:
- Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch

You Pay
When performed in a Blue Distinction Center for Comprehensive Bariatric Surgery: 30% of the Plan allowance (deductible applies)

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

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 the service.

Surgical Procedures - continued on next page

Go to page 56. Go to page 58.