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.

Gender affirming services

(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, 55970, 55980, 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, 15770, 15769, 15773, 15774, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 17380, 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

Preauth required for Gender Dysphoria diagnosis code(s) F640, F641, F642, F648, F649, Z87890.

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

C9172, J1411, J1412, J1413, J1414, J3392, J3393, J3394, J3398, J3399, J3401, J9029, J9325, J9380, Q2041, Q2042, Q2043, Q2053, Q2054, Q2055, Q2056, S2107, 38225, 38226, 38227, 38228

Bariatric surgery

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

Hospice services

Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5009, Q5010, S0255, S0271 or S9126

Preauth is required for home hospice, continuous home hospice, or inpatient hospice care services.

Genetic testing

G0452, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3852, S3853, S3854, S3861, S3865, S3866, S3870, 0001U, 0004M, 0005U, 0006M, 0007M, 0008U, 0009U, 0010U, 0011M, 0012M, 0013M, 0016M, 0017M, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0055U, 0060U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0087U, 0088U, 0089U, 0090U, 0091U, 0094U, 0101U, 0102U, 0103U, 0111U, 0112U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0249U, 0250U, 0252U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0295U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0327U, 0329U, 0331U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0356U, 0362U, 0363U, 0364U, 0368U, 0378U, 0379U, 0388U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0463U, 0464U, 0465U, 0466U, 0467U, 0469U, 0470U, 0471U, 0473U, 0474U, 0475U, 0488U, 0489U, 0495U, 0496U, 0498U, 0499U, 0500U, 0501U, 0506U, 0507U, 0523U, 0529U, 0530U

81120, 81121, 81161, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81195, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81425, 81426, 81427, 81430, 81431, 81432, 81434, 81435, 81436, 81437, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81479, 81493, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81528, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81558, 81595, 81599, 88245, 88248, 88249 88283, 88285, 88289 or 88291

Air ambulance transport (non-emergent)

(Revenue Code) 0540, 0541, 0542, 0543, 0544, 0546, 0547, 0548, 0549

(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

(Procedure Code) 77520, 77522, 77523, 77525, G0563

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

(Procedure Code) 77371, 77372, 77432

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

C9173, C9257, J0222, J0223, J0224, J0177, J0178, J0179, J0225, J0885, J1300, J1303, J1442, J1447, J1449, J1602, J1745, J1748, J2327, J2350, J2506, J2777, J2778, J3357, J3358, J9035, J9311, J9312, J9332, J9334, J9355, J9356, Q5101, Q5103, Q5104, Q5106, Q5107, Q5108, Q5109, Q5110, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5124, Q5125, Q5126, Q5127, Q5128, Q5129, Q5130, Q5137, Q5138, Q5139, Q5146, Q9996, Q9997, Q9998

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, 25682000101 or 73475304105

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

V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5120, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5265, V5298, V5299

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