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Prior Approval - Federal Employee Program (FEP)

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

 

If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. You may also view the prior approval information in the Service Benefit Plan Brochures .

Procedures requiring prior approval for FEP members

Standard & Basic Option

Gene therapy and cellular immunotherapy

Required.

Air ambulance transport (non-emergent)

Transport related to immediate care of a medical emergency or accidental injury does not require prior approval.

Outpatient sleep studies performed outside the home

Required for sleep studies performed in a provider’s office, sleep center, clinic, outpatient center, hospital, skilled nursing facility, residential treatment center and any other location that is not the member’s home.
Applied behavior analysis (ABA)

Required for ABA and all related services, including assessments, evaluations, and treatments. For more detail, refer to the medical policy .

 

Gender reassignment surgery Prior to surgical treatment of gender dysphoria, a treatment plan must be submitted that includes 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 the plan is later modified.

 

See the current Standard and Basic Option Service Benefit Plan brochure  for additional information.

 

BRCA/LGR testing

Required for both preventive and diagnostic testing.

 

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 — See the Standard and Basic Option Service Benefit Plan brochure  for specific pre-surgical criteria that must be met.
  • Outpatient surgical correction of congenital anomalies.Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
  • Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
Outpatient intensity-modulated radiation therapy (IMRT)

Required for all outpatient IMRT services except IMRT related to the treatment of head, neck, breast, prostate cancer 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.

 

Hospice care

Includes home hospice, continuous home hospice, or inpatient hospice care services.

 

Organ/tissue transplants Prior approval is required for both the procedure and the facility. Prior approval is also required for travel benefits associated with a Blue Distinction Center for transplant facility approval.

 

See the Standard and Basic Option Service Benefit Plan brochure  for the list of covered 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 CVS Caremark®, our pharmacy program administrator, at 800-624-5060 to request prior approval or to obtain a list of drugs and supplies that require prior approval.

 

Note: Updates to the list of drugs and supplies requiring prior approval are made periodically during the year.

Medical foods covered under the pharmacy benefit

Required.
Residential treatment center (RTC)

A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (RTC), and case manager in the local plan where the RTC is located prior to admission.

 

 

Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for 90 days, 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:

 

View FEP medical policies

 

FEP Blue Focus

Penalty Note: You must obtain prior approval for these services. Failure to obtain prior approval will result in a $100 penalty. Pre-certification is also required if the service or procedure requires an inpatient hospital admission.

 

Gene therapy and cellular immunotherapy

Required.
Air ambulance transport (non-emergent)

Transport related to immediate care of a medical emergency or accidental injury does not require prior approval.

 

Applied behavior analysis (ABA)

Required for ABA and all related services, including assessments, evaluations, and treatments. For more details, refer to the medical policy .

 

Cochlear implants

Required.

 

Gender reassignment surgery

Prior to surgical treatment of gender dysphoria, a treatment plan must be submitted that includes 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 the plan is later modified.

 

BRCA/LGR testing

Required for both preventive and diagnostic testing.

 

Radiology, high technology

All, including CT scan/MRIs/PET scan services.
Hospice care

Includes home hospice, continuous home hospice, or inpatient hospice care services.

 

Transplants

Required for all transplants, except cornea and kidney. See the FEP Blue Focus Service Benefit Plan brochure  for the list of covered organ/tissue transplants. Prior approval is required for both the procedure and the facility. Prior approval is also required for travel benefits associated with a Blue Distinction Center for Transplants facility approval.

 

Oral and maxillofacial surgery

Prior approval is required, except when related to an accidental injury and provided within 72 hours of the accident.

 

Outpatient intensity-modulated radiation therapy (IMRT)

Required for all outpatient IMRT services except IMRT related to the treatment of head, neck, breast, anal or prostate cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.

 

Outpatient cardiac rehab

Required.

 

Outpatient residential treatment

 

Required for any condition.
Clinical trials for certain organ/tissue transplants

A transplant clinical trial may not be available for your condition. If you or your provider are considering a clinical trial, please contact us at the telephone number on the back of your FEP Blue Focus ID card for assistance in determining if a covered clinical trial is available in a covered facility.

 

Prescription drugs Certain prescription drugs under our retail or mail-order pharmacy programs require prior approval. Contact CVS Caremark, our pharmacy program administrator, at 800-624-5060 to request prior approval or to obtain a list of drugs and supplies that require prior approval.

 

Note: Updates to the list of drugs and supplies requiring prior approval are made periodically during the year.

 

Prosthetic devices (external) and specialty DME

Includes but not limited to specialty hospital beds, deluxe wheelchairs, power wheelchairs, mobility devices including scooters, microprocessor limb prosthesis, electronic and externally powered prosthesis and related supplies.

 

Pulmonary rehabilitation

Required.

 

Residential treatment center (RTC)

A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (RTC), and case manager in the local plan where the RTC is located prior to admission.

 

Surgical services See the FEP Blue Focus Service Benefit Plan brochure  for details on the following surgeries:
  • Morbid obesity
  • Gender reassignment surgery
  • Oral maxillofacial
  • Congenital anomalies
  • Breast reduction / augmentation
  • Reconstructive surgery for conditions other than breast cancer
  • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management temporomandibular joint (TMJ)
  • Other — hip, knee, ankle, spine, shoulder, rhinoplasty, septoplasty, varicose vein, and all orthopedic procedures using computer-assisted musculoskeletal surgical intervention

 

Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for 90 days, 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:

View FEP medical policies 


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