2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
You need prior Plan approval for certain services:
Other services
Section 3. How You Get Care
You need prior Plan approval for certain services:
Other services
- Other services
- Gene Therapy and Cellular Immunotherapy, including Car-T and T-cell receptor therapy
- 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
- 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
- Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
- Hospice care – Prior approval is required for home hospice, continuous home hospice, or inpatient hospice care services. We will advise you which home hospice care agencies we have approved. See page 78 for information about the exception to this requirement.
- Cardiac rehabilitation
- Cochlear implants
- Residential treatment center care for any condition
Note: See pages 23-24 for special situations when another payor is primary.
- Prosthetic devices (external), including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis
- Pulmonary rehabilitation
- Radiology, high technology including:
- Magnetic resonance imaging (MRI)
- Computed tomography (CT) scan
- Positron emission tomography (PET) scan
Note: High technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval.
- Magnetic resonance imaging (MRI)
- Specialty durable medical equipment (DME), rental or purchase, to include:
- Specialty hospital beds
- Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies
- Specialty hospital beds
- Transplants: Prior Approval is required for all transplants, except cornea and kidney. Prior approval is required for both the procedure and if benefits require, the transplant program; precertification is required for inpatient care.
- Blood or marrow stem cell transplants listed on pages 63-65 must be performed in a transplant program designated as a Blue Distinction Center for Transplants. See page 17 for more information about these types of programs.
Not every transplant program provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the transplant program is specifically designated as a Blue Distinction Center for Transplants for that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number appearing on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
- Clinical trials for certain blood or marrow stem cell transplants – See pages 64-65 for the list of conditions covered only in clinical trials.
- Contact us at the customer service phone number on the back of your ID card for information or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage determination.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a Blue Distinction Center for Transplants to treat your condition. If your physician has recommended you receive a transplant or that you participate in a transplant clinical trial, we encourage you to contact the Case Management Department at your Local Plan.
Note: For the purposes of the blood or marrow stem cell clinical trial transplants covered under this Plan, a clinical trial is a research study whose protocol has been reviewed and approved by the Institutional Review Board (IRB) of the Blue Distinction Center for Transplants where the procedure is to be performed.
- Organ/tissue transplants
Benefits for certain transplants are limited to designated transplant centers or programs.
Transplants listed on page 66 must be performed in a transplant program designated as a Blue Distinction Center for Transplants.
The organ transplants listed on page 66 are not available in a Blue Distinction Center for Transplants and must be performed at a Preferred facility with a Medicare-Approved Transplant Program, if one is available.
Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.
If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not apply and you may use any covered Preferred facility and Preferred provider that performs the procedure.
Contact us at the customer service phone number listed on the back of your ID card before obtaining services. We will request the medical evidence we need to make our coverage determination. Our review will include whether you meet the facility and transplant program criteria for the particular transplant.
All members (including those who have Medicare Part A or another group health insurance policy as their primary payor) must contact us at the customer service phone number listed on the back of their ID card before obtaining services.
- Transplant travel – If you travel to a Blue Distinction Center for Transplants, we reimburse up to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for you and your traveling companions) if you live 50 miles or more from the facility.
- Prescription drugs and supplies – Certain prescription drugs and supplies, including medical foods administered orally (see pages 94 and 131), require prior approval. Contact CVS Caremark, our Pharmacy Program administrator, at 800-624-5060, TTY: 711, to request prior approval, or to obtain a list of drugs and supplies that require prior approval. We will request the information we need to make our coverage determination. You must periodically renew prior approval for certain drugs. See page 92 for more information about our prescription drug prior approval program, which is part of our Patient Safety and Quality Monitoring (PSQM) program.
Notes:
- Updates are made periodically throughout the year to the list of drugs and supplies requiring prior approval. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
- Until we approve them, you must pay for these drugs in full when you purchase them – even if you purchase them at a Preferred retail pharmacy or through our specialty drug pharmacy – and submit the expense(s) to us on a claim form. Preferred pharmacies will not file these claims for you.
- The Specialty Drug Pharmacy Program will not fill your prescription until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be returned to you along with a letter explaining the prior approval procedures.
- Updates are made periodically throughout the year to the list of drugs and supplies requiring prior approval. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
• Warning:
We will reduce our benefits by $100 for medically necessary services that require prior approval, if no one contacts us for prior approval. If the service is not medically necessary, we will not provide benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see page 22.