PSHB 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 68
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 68
Benefit Description
Reconstructive Surgery
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.
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.
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
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.
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.
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