2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 20

 

  • High-cost drugs – We require prior approval for certain high-cost drugs obtained outside of a pharmacy setting. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs.
     
  • Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate care of a medical emergency or accidental injury does not require prior approval; see Section 5(c), page 80, for more information.
     
  • Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
     
  • Genetic testing including the following:
     
    • BRCA screening or diagnostic testing
       
    • Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing
       
    • Genetic testing for the diagnosis and/or management of an existing medical condition
Note: Necessary medical evidence for BRCA-related genetic testing includes the results of genetic counseling.
 
  • Surgical services – The surgical services on the following list require prior approval and when care is provided in an inpatient setting, precertification is required for the hospital stay.
     
    • Procedures to treat morbid obesity (see pages 57-58)

      Note: Benefits for the surgical treatment of morbid obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed on page 58. Benefits are only available for the surgical treatment of morbid obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) surgery.

      Note: See pages 23-24 for special situations when another payor is primary.
       
    • Breast reduction or augmentation not related to treatment of cancer
       
    • Gender affirming surgery – Prior to surgical treatment of gender dysphoria, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan.

      Note: See pages 23-24 for special situations when another payor is primary.
       
    • Surgical correction of congenital anomalies (see definition on page 129)
       
    • Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures
       
    • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
       
    • Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation
       
    • Reconstructive surgery for conditions other than breast cancer
       
    • Rhinoplasty
       
    • Septoplasty
       
    • Varicose vein treatment
       
  • Intensity-modulated radiation therapy (IMRT) – Prior approval is required for all IMRT services except IMRT related to the treatment of head, neck, breast, prostate or anal cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
     
  • Proton beam therapy, stereotactic radiosurgery, and stereotactic body radiation therapy

 

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