2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 20
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
- BRCA screening or diagnostic testing
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
- Procedures to treat morbid obesity (see pages 57-58)
- 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