2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Reconstructive Surgery

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

Benefit Description

Reconstructive Surgery
 

• Surgery to correct a functional defect
   
• Surgery to correct a congenital anomaly
   
• Treatment to restore the mouth to a pre-cancer state
   
• All stages of breast reconstruction surgery following a mastectomy, such as:
   
  • Surgery to produce a symmetrical appearance of the patient’s breasts
     
  • Treatment of any physical complications, such as lymphedemas
    
    Note: Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
    
    Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
     
• Surgery for placement of penile prostheses to treat erectile dysfunction

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.

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)
   
• Sex-Trait Modification: 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