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Prior Approval - Federal Employee Program (FEP)

A prior approval review determines medical necessity and considers Federal Employee Program (FEP) benefits before a treatment, procedure, service, or supply is provided. FEP Standard and Basic Option plans require a prior approval for the procedures listed below.

Procedures Requiring Prior Approval for FEP Members

• Outpatient surgical services – The surgical services listed below require prior approval when they are to be performed on an outpatient basis. This requirement applies to both the physician and facility services.
  • Outpatient surgery for morbid obesity
  • Outpatient surgical correction of congenital anomalies
  • Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth

• Outpatient intensity-modulated radiation therapy (IMRT) - Required beginning 2010.

• Hospice care - Includes home hospice, continuous home hospice, or inpatient hospice care services.
• Outpatient mental health and substance abuse treatment, including partial hospitalizations and intensive outpatient services
• Organ/tissue transplants 
• Clinical trials for certain organ/tissue transplants – Contact our Transplant Clinical Trials Information Unit at 800-225-2268 for information or to request prior approval.
• Prescription drugs – Certain prescription drugs under our Retail or Mail Order Pharmacy programs require prior approval. Contact our Retail Pharmacy Program at 800-624-5060 to request prior approval or to obtain an updated list of prescription drugs that require prior approval. Note: Benefits for drugs to aid smoking cessation that require a prescription by Federal law are limited to one course of treatment per calendar year. Prior approval is required before benefits will be provided for additional medication. To obtain approval, the physician must certify that the patient is participating in a smoking cessation program that provides clinical treatment, including counseling and behavioral therapies.

Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for 6 months, as long as the patient’s benefits do not change between the date the approval is given and the date the service is provided.

You will receive a written response within 15 calendar days of receipt of the request. 

To request a review of medical necessity and FEP benefits:

• Submit a Prior Approval online (if you have secure access to Wellmark.com) 
• Complete and fax the Federal Employee Program (FEP) Prior Approval Form  (112KB)

For more information, see the 2010 Service Benefit Plan brochure (pages 16–17) at www.fepblue.org.