2026 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 21

 

  • Medical benefit drugs – We require prior approval for certain drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs 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.
     
  • Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
     
  • Genetic testing - prior approval for genetic testing will be required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease.  
     
  • 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 severe obesity 
    Note: Benefits for the surgical treatment of severe obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed in our Bariatric medical policy. See Section 5(b). Benefits are only available for the surgical treatment of severe obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) Surgery.
     
  • Breast reduction or augmentation not related to treatment of cancer
     
  • 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
     
  • Proton beam therapy – Prior approval is required for all proton beam therapy services except for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas.
     
  • Stereotactic radiosurgery – Prior approval is required for all stereotactic radiosurgery except when related to the treatment of malignant neoplasms of the brain and of the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.  
     
  • Stereotactic body radiation therapy
     
  • Reproductive services – Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI)
     
  • Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
     
  • Cardiac rehabilitation
     
  • Cochlear implants
     
  • Residential treatment center care for any condition