FEHB Standard and Basic Options
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 66
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 66
Benefit Description
Oral and Maxillofacial Surgery (cont.)
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Note: You pay 35% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
Oral and Maxillofacial Surgery (cont.)
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Note: You pay 35% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Oral implants and transplants except for those required to treat accidental injuries as specifically and previously described and in Section 5(g)
- Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically and previously described and in Section 5(g)
- Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically and previously described and in Section 5(g)
- Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically and previously described and in Section 5(g)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Organ and Tissue Transplants
Solid organ/tissue transplants are subject to medical necessity and experimental/investigational review. For the solid organ transplants listed below, you must obtain prior approval from the Local Plan for the procedures, and you must obtain precertification for the facility. (See precertification and prior approval in Section 3.)
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
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.
Organ and Tissue Transplants
Solid organ/tissue transplants are subject to medical necessity and experimental/investigational review. For the solid organ transplants listed below, you must obtain prior approval from the Local Plan for the procedures, and you must obtain precertification for the facility. (See precertification and prior approval in Section 3.)
- Heart transplant
- Heart-lung transplant
- Kidney transplant
- Liver transplant
- Pancreas transplant
- Combination liver-kidney transplant
- Combination pancreas-kidney transplant
- Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
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
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.
Organ and Tissue Transplants - continued on next page