Federal Employee Program® Updates to Prior Authorization Requirements and Benefits

December 19, 2023

As of Jan. 1, 2024, the following changes will be in effect for FEP® policy types:

  • For Standard and Basic, hearing aids will require prior authorization and will not be covered with a post service review. Blue Focus will continue to not cover hearing aids.
  • All genetic testing will require prior authorization.
  • Proton Beam Therapy, Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy require prior authorization.
  • Certain High-Cost High Dollar drugs will require prior authorization in addition to all gene therapy and CAR-T drugs.
  • All transplants require prior authorization, regardless of policy type, except corneal.
  • Gender Affirming Care will include breast augmentation and certain facial surgeries. All gender affirming services still require prior authorization.
  • We now provide coverage for artificial insemination; prior authorization is required.
  • Benefits for drugs associated with artificial insemination procedures, where the procedure has been prior approved, may be covered.
  • In vitro fertilization related drugs are limited to three cycles annually, prior authorization required and must be completed through the pharmacy benefit.
  • For Standard members, we provide coverage for Assisted Reproductive Technology procedures and services, limited to $25,000 annually for some infertility diagnosis. Prior authorization is required.
  • We no longer require written consent in a case management program prior to admission for inpatient care provided by a Residential Treatment Center or Skilled Nursing Facility.
  • We now provide coverage for marital and family counseling.
  • For eligible members who don’t opt out, prescription drug benefits will be provided under a new FEP Medicare Prescription Drug Program (Medicare Part D).

You may submit a request via Availity® Essentials. You can also submit a fax along with the Recommended Clinical Review (Predetermination) form to 877-404-6455 or by calling 800-227-6591. 

To verify coverage, or for more information on your patient’s benefits, call the number on the member’s BCBSIL ID card.

Visit our website for more information about FEP.

Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations, or warranties regarding third party vendors and the products and services they offer.

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSIL ID card.