FEP Blue Standard™/ FEP Blue Basic™

Transplants - artificial heart

33927, 33928, 33929

Transplants - blood or marrow stem cell transplants

(Transplant) 38240, 38241, S2142, S2150

(Donor) 38205, 38206, 38207, 38230, 38232, S2140

Bone marrow transplants may require Blue Distinction Centers for transplants facility.

Transplants - organ/tissue

(Transplant) 32851, 32852, 32853, 32854, 33935, 33945, 44135, 44136, 47135, 48160, 48554, 0584T, 0585T, 0586T, G0341, G0342, G0343, S2053, S2054, S2060, S2065, S2152

(Donor) 0494T, 0495T, 0496T, 0894T, 0895T, 0896T, 32850, 33930, 33940, 44132, 44133, 47133, 47140, 47141, 47142, 48550, S2055, S2061

(Backbench) 32855, 32856, 33933, 33944, 44715, 44720, 44721, 47143, 47144, 47145, 47146, 47147, 48551, 48552

Transplants - kidney

(Transplant) 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50380

(Donor) 50547

Applied Behavior Analysis (ABA) services

0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

Preauth required for Autism Spectrum Disorder diagnosis code(s) F840, F843, F845, F848, F849.

Sex trait modification is not covered OR requires PA for mid-treatment exception

For mid-treatment exceptions ONLY, PA is required when the diagnosis code is one of the following: F640, F641, F642, F648, F649, Z87890 AND Procedure code is one of the following:

(Gender affirming surgery Procedure codes) 11920, 11921, 11922, 11970, 15771, 15772, 15877, 19303, 19318, 19325, 19350, 19357, 53410, 53430, 54125, 54400, 54401, 54405, 54660, 54520, 54690, 55175, 55180, 55899, 56625, 56805, 57110, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 58999, C1789, C1813, C2622, L8600

(Gender affirming facial surgery) 11950, 11951, 11952, 11954, 15769, 15770, 15773, 15774, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 21025, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21215, 21230, 21235, 21244, 21245, 21246, 21248, 21249, 21270, 21899, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 40799, 67900, 69300

(Electrolysis performed at the operative site for a gender affirming surgery) 17380

(Gender affirming specific drug Procedure codes) J1000, J1380, J1950, J1951, J1952, J1954, J9217, J9218, J9219, J1071, J1072, J3121, J3315, J3316 or J9202

Or, the Procedure code is: 55970 or 55980

Preauth required for mid-treatment exceptions only. Otherwise sex-trait modification is not covered.

Outpatient facility-based sleep studies

95782, 95783, 95803, 95805, 95807, 95808, 95810, 95811

Preauth is required for sleep studies performed in a provider’s office, sleep center, clinic, any type of outpatient center, or any location other than the home.

Gene therapy and cellular immunotherapy

J1411, J1412, J1413, J1414, J3391, J3392, J3393, J3394, J3398, J3399, J3401, J3402, J3403, J9029, J9325, Q2041, Q2042, Q2043, Q2053, Q2054, Q2055, Q2056, Q2057, Q2058, S2107, 38225, 38226, 38227, 38228

Bariatric surgery

0813T, 43290, 43291, 43644, 43645, 43770, 43771, 43773, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43888, 43889, C9784, C9785

Oral/Maxillofacial surgery

21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215,  21244, 21245, 21246, 21247, 21248, 21249, 21440, 21445, 21452, 21454, 21255, 21270, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21450, 21451, 21453, 21461, 21462, 21465, 21470, 40510, 40520, 40525, 40527, 40650, 40652, 40654, 40804, 40805, 40830, 40831, 41250, 41251, 41252, 42180, 42182 or 40530, D7530, D7540, D7610, D7620, D7630, D7640, D7650, D7660, D7670, D7671, D7680, D7710, D7720, D7730, D7740, D7750, D7760, D7770, D7771, D7780, D7910, D7911, D7912, D7920, D7946, D7947, D7948, D7949, D7993, D7994, D7995, D7996

Preauth is required except when care is provided within 72 hrs of an accidental injury.

Genetic testing

PA required when Procedure code is one of the following: S3852, S3861, 0012M, 0091U, 0094U, 0101U, 0102U, 0103U, 0129U, 0130U, 0133U, 0134U, 0136U, 0137U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0212U, 0213U, 0214U, 0215U, 0231U, 0235U, 0237U, 0238U, 0265U, 0335U, 0336U, 0368U, 0400U, 0405U, 0410U, 0421U, 0425U, 0426U, 0464U, 0469U, 0474U, 81201, 81203, 81206, 81207, 81208, 81220, 81222, 81223, 81225, 81226, 81227, 81242, 81243, 81244, 81245, 81252, 81257, 81258, 81259, 81288, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81307, 81317, 81322, 81324, 81325, 81326, 81327, 81351, 81352, 81353, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81430, 81431, 81432, 81435, 81437, 81439, 81441, 81443, 81455, 81456, 81460, 81465, 81470, 81471, 81479, 81528, 81599, 0582U or 0583U ANDPrincipal Diagnosis Code is one of the following diagnosis codes: Z0000, Z00110, Z00111, Z00121, Z00129, Z008, Z01419, Z120, Z1210, Z1211, Z1212, Z1213, Z122, Z1231, Z1239, Z124, Z125, Z126, Z1271, Z1272, Z1273, Z1279, Z1281, Z1282, Z1283, Z1289, Z129, Z1401, Z141, Z148, Z1501, Z1502, Z1503, Z1504, Z1505, Z1507, Z1509, Z15060, Z15068, Z151, Z152, Z153, Z1581, Z1589, Z3009, Z308, Z309, Z3141, Z31430, Z31438, Z31440, Z31448, Z3149, Z315, Z3161, Z3162, Z3169, Z317, Z3181, Z3182, Z3183, Z3184, Z3189, Z319, Z3200, Z3201, Z3202, Z331, Z7183, Z7189, Z719, Z800, Z801, Z802, Z803, Z8041, Z8042, Z8043, Z8049, Z8051, Z8052, Z8059, Z806, Z807, Z808, Z809, Z810, Z811, Z812, Z813, Z814, Z818, Z820, Z821, Z822, Z823, Z8241, Z8249, Z825, Z8261, Z8262, Z8269, Z8271, Z8279, Z828, Z830, Z831, Z832, Z8341, Z8342, Z83430, Z83438, Z8349, Z83511, Z83518, Z8352, Z836, Z83710, Z83711, Z83718, Z83719, Z8372, Z8379, Z840, Z8411, Z8419, Z842, Z843, Z8481, Z8482 or Z8489

Air ambulance transport (non-emergent)

(Revenue code) 0545; Or Revenue code is one of the following 0540, 0541, 0542, 0543, 0544, 0546, 0547, 0548, 0549, and Procedure code is listed below.

(Procedure code) A0430, A0431, A0435, A0436

Preauth is NOT required for air ambulance transport related to immediate care of a medical emergency or accidental injury.

BRCA testing

0138U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

Proton beam therapy

(Revenue code) 0333

PA required for members 22 years of age and older, when the Procedure code is one of the following: (Procedure code) 77520, 77522, 77523, 77525, G0563 AND The diagnosis code is NOT one of the following: C37, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C720, C721, C7220, C7221, C7222, C7230, C7231, C7232, C7240, C7241, C7242, C7250, C7259, C729, C7A091, C7931, C7949, C8100, C8101, C8102, C8103, C8104, C8105, C8106, C8107, C8108, C8109, C8110, C8111, C8112, C8113, C8114, C8115, C8116, C8117, C8118, C8119, C8120, C8121, C8122, C8123, C8124, C8125, C8126, C8127, C8128, C8129, C8130, C8131, C8132, C8133, C8134, C8135, C8136, C8137, C8138, C8139, C8140, C8141, C8142, C8143, C8144, C8145, C8146, C8147, C8148, C8149, C8170, C8171, C8172, C8173, C8174, C8175, C8176, C8177, C8178, C8179, C8190, C8191, C8192, C8193, C8194, C8195, C8196, C8197, C8198, C8199, C8200, C8201, C8202, C8203, C8204, C8205, C8206, C8207, C8208, C8209, C8210, C8211, C8212, C8213, C8214, C8215, C8216, C8217, C8218, C8219, C8220, C8221, C8222, C8223, C8224, C8225, C8226, C8227, C8228, C8229, C8230, C8231, C8232, C8233, C8234, C8235, C8236, C8237, C8238, C8239, C8240, C8241, C8242, C8243, C8244, C8245, C8246, C8247, C8248, C8249, C8250, C8251, C8252, C8253, C8254, C8255, C8256, C8257, C8258, C8259, C8260, C8261, C8262, C8263, C8264, C8265, C8266, C8267, C8268, C8269, C8280, C8281, C8282, C8283, C8284, C8285, C8286, C8287, C8288, C8289, C8290, C8291, C8292, C8293, C8294, C8295, C8296, C8297, C8298, C8299, C8300, C8301, C8302, C8303, C8304, C8305, C8306, C8307, C8308, C8309, C8310, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318, C8319, C8330, C8331, C8332, C8333, C8334, C8335, C8336, C8337, C8338, C8350, C8351, C8352, C8353, C8354, C8355, C8356, C8357, C8358, C8359, C8370, C8371, C8372, C8373, C8374, C8375, C8376, C8377, C8378, C8379, C8380, C8381, C8382, C8383, C8384, C8385, C8386, C8387, C8388, C8389, C8390, C8391, C8392, C8393, C8394, C8395, C8396, C8397, C8398, C8399, C8400, C8401, C8402, C8403, C8404, C8405, C8406, C8407, C8408, C8409, C8410, C8411, C8412, C8413, C8414, C8415, C8416, C8417, C8418, C8419, C8440, C8441, C8442, C8443, C8444, C8445, C8446, C8447, C8448, C8449, C8460, C8461, C8462, C8463, C8464, C8465, C8466, C8467, C8468, C8469, C8470, C8471, C8472, C8473, C8474, C8475, C8476, C8477, C8478, C8479, C847A, C84A0, C84A1, C84A2, C84A3, C84A4, C84A5, C84A6, C84A7, C84A8, C84A9, C84Z0, C84Z1, C84Z2, C84Z3, C84Z4, C84Z5, C84Z6, C84Z7, C84Z8, C84Z9, C8490, C8491, C8492, C8493, C8494, C8495, C8496, C8497, C8498, C8499, C8510, C8511, C8512, C8513, C8514, C8515, C8516, C8517, C8518, C8519, C8520, C8521, C8522, C8523, C8524, C8525, C8526, C8527, C8528, C8529, C8580, C8581, C8582, C8583, C8584, C8585, C8586, C8587, C8588, C8589, C8590, C8591, C8592, C8593, C8594, C8595, C8596, C8597, C8598, C8599, D330, D331, D332, D333, D334, D337, D339, D420, D421, D429, D430, D431, D432, D433, D434, D438, D439, D496

Preauth is NOT required for patients 21 years of age 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 body radiation therapy

(Revenue code) 0333

(Procedure code) 77373, 77435, G0563

Stereotactic radiosurgery

(Revenue code) 0333

PA required when procedure code is one of the following: (Procedure code) 77371, 77372, 77432

AND Diagnosis code is NOT one of the following: (Diagnosis code) C6930, C6931, C6932, C6940, C6941, C6942, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C7931, D320, D333, D352, D356, D444, D447, G500, G9381, Q280, Q281, Q282

Preauth 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.

Medical benefit drugs

C9257, C9305, J0222, J0223, J0224, J0177, J0178, J0179, J0225, J0881, J0885, J0897, J1299, J1303, J1442, J1447, J1449, J1459, J1551, J1552, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1602, J1745, J1748, J2323, J2326, J2327, J2329, J2350, J2351, J2506, J2777, J2778, J3241, J3357, J3358, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J9035, J9042, J9144, J9271, J9299, J9306, J9311, J9312, J9332, J9333, J9334, J9354, J9355, J9356, J9358, Q5098, Q5099, Q5100, Q5101, Q5103, Q5104, Q5106, Q5107, Q5108, Q5110, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5124, Q5125, Q5126, Q5127, Q5128, Q5129, Q5130, Q5134, Q5136, Q5137, Q5138, Q5146, Q5147, Q5148, Q5149, Q5150, Q5151, Q5152, Q5153, Q5155, Q5156, Q5157, Q5158, Q5159, Q9996, Q9997, Q9998, Q9999 OR Unclassified drug code(s) C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999, or Q0181 ONLY when NDC is: 72126000701, 72126000702, 71336100001, 71336100101, 71336100201, 72606002901, 72606002701, 72606002801, 25682000101, 73475304105, 83257002611, 83257002411, 83257002341, 83257002541

Sperm or egg storage

89343, 89344, 89346

Preauth is required for the storage of sperm and eggs for individuals facing iatrogenic infertility

In vitro fertilization

58323, 58970, 58974, 58976, 76948, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89337, 89342, 89343, 89344, 89346, 89352, 89353, 89354, 89356, S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4027, S4028, S4030, S4031, S4037 or S4040, S4042

***Standard Option ONLY

Hearing aid services

92634, 92635, 92636, 92637, V5011, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5171, V5172, V5181, V5190, V5200, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5265, V5267, V5275, V5298, V5299

Hip, knee, or spine surgery

(Hip Procedure codes) 27125, 27130

(Knee Procedure codes) 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

(Spine Procedure codes) 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22856, 22857, 22867, 22869, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63050, 63051, 63052, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307

Sperm or egg storage

89343, 89344, 89346

Preauth is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.

Artificial insemination (AI) drugs

J0725, J1675, J1950, J1951, J1952, J2675, J3315, J3316, J9155, J9202, J9217, J9218, J9225, J9226, S0122, S0126, S0128, S0132

OR

Unclassified drug code(s) C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999, Q0181, S5000, or S5001 ONLY with an applicable (AI drug) NDC

Artificial insemination services

58321, 58322, 58323, 89257, 89260, 89261, 89264, 89353, 89354, S4028, S4035, S4042