2026 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 65

 

Benefit Description

Not covered:
  • Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth) (See Section 5(d) for Accidental Injury benefits) 
  • Surgery for Sex-Trait Modification to treat gender dsyphoria: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service phone number listed on the back of your ID card. If you disagree with our decision, please see Section 8 of this brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria. 


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges

 

 

Benefit Description

Oral and Maxillofacial Surgery
Oral surgical procedures, limited to:
 
  • Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
     
  • Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth

    Note: Prior approval is required for oral/maxillofacial surgery needed to correct accidental injuries as described above, except when care is provided within 72 hours of the accidental injury. Please refer to Section 3 for more information.
     
  • Excision of exostoses of jaws and hard palate
     
  • Incision and drainage of abscesses and cellulitis
     
  • Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
     
  • Reduction of dislocations and excision of temporomandibular joints
     
  • Removal of impacted teeth


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: 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.

 

Oral and Maxillofacial Surgery - continued on next page