2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 3. How You Get Care
Page 22
Section 3. How You Get Care
Page 22
• Other services
You must obtain prior approval for these services under both Standard and Basic Option in all outpatient and inpatient settings unless otherwise noted. Precertification is also required if the service or procedure requires an inpatient hospital admission. Contact us using the customer service phone number listed on the back of your ID card before receiving these types of services, and we will request the medical evidence needed to make a coverage determination:
You must obtain prior approval for these services under both Standard and Basic Option in all outpatient and inpatient settings unless otherwise noted. Precertification is also required if the service or procedure requires an inpatient hospital admission. Contact us using the customer service phone number listed on the back of your ID card before receiving these types of services, and we will request the medical evidence needed to make a coverage determination:
- Gene therapy and cellular immunotherapy, for example 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 92, for more information.
- Outpatient facility-based sleep studies – Prior approval is required for sleep studies performed in a provider’s office, sleep center, clinic, any type of outpatient center, or any location other than your home.
- Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
- 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.
- BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes – Prior approval is required for BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes whether performed for preventive or diagnostic reasons.
Note: You must receive genetic counseling and evaluation services before preventive BRCA testing is performed. See page 44.
- Surgical services – The surgical services on the following list require prior approval for care performed by Preferred, Participating/Member, and Non-participating/Non-member professional and facility providers:
- Surgery for morbid obesity;
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 64-65.
- Surgical correction of congenital anomalies (see definition on page 152);
- Surgery needed to correct accidental injuries (see definition on page 152) to jaws, cheeks, lips, tongue, roof and floor of mouth except when care is provided within 72 hours of the accidental injury
- Surgery for morbid obesity;
- 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 90 for information about the exception to this requirement.