2026 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Blue Focus Form

2025 FEP Blue Focus; effective on January 1, 2025 Updated: December 2, 2024 2026 Federal Employee Program (FEP) Prior Approval/Pre-Certification List for: • Federal Employee Health Benefit Blue Focus or • Postal Employee Health Benefit Blue Focus Please note: There is a separate Prior Approval/Pre-Certification list for the FEP Standard Option and Basic Option products for Federal Employee Health Benefit and Postal Employee Health Benefit. Federal Employee Program members only require prior approval or pre-certification on the following services, which are based on medical necessity. For a complete quote of benefit information, please contact the local Blue Cross and Blue Shield plan on the back of the patient’s identification card. *If another carrier is primary (such as Medicare), prior approval/pre-certification may be required. See the grid at the end of this document for full details. Services requiring Pre-Certification: • Inpatient hospital admissions • Inpatient residential treatment centers

Services requiring Prior Approval: Air Ambulance Transport (non-emergent) Prior approval is required for all non-emergent air ambulance transports. Air ambulance transports related to immediate care, or a medical emergency or accidental injury does not require prior approval.

Applied Behavioral Analysis (ABA) Prior approval is required for all ABA and all related services, including assessments, evaluations and treatments.

Cardiac Rehabilitation

Cochlear Implants

Durable Medical Equipment (DME) – Specialty Prior approval is required for all specialty DME to include: • Specialty hospital beds • Deluxe wheelchairs, power wheelchairs, and mobility devices and related supplies

Gene Therapy and Cellular Immunotherapy Prior approval is required for all gene therapy and cellular immunotherapy, including: • CAR-T
• T-cell receptor therapy

Genetic Testing Prior approval is required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and

2025 FEP Blue Focus; effective on January 1, 2025 Updated: December 2, 2024 symptoms of genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease. If you are unsure whether a genetic test requires prior authorization, contact FEP customer service.

Medical Benefit Drugs (previously titled High-Cost Drugs) Prior approval is required for certain drugs submitted on a medical claim for reimbursement. Contact FEP customer service (800) 328-0365 or visit www.fepblue.org/medicalbenefitdrugs for a list of drugs requiring prior approval.

Prescription Drugs Certain prescription drugs require prior approval. Contact CVS Caremark, our Pharmacy Program administrator at (800) 624-5060 to request prior approval or to obtain and updated list of prescription drugs that require prior approval. You must periodically renew prior approval for certain drugs.

Prosthetic Devices (external) Prior approval is required for external prosthetic devices including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis.

Proton Beam Therapy Prior approval is required for all proton beam therapy services except for members aged 21 or younger, or when related to the treatment of neoplasm of the nervous system including the brain and spinal cord; malignant neoplasm of the thymus; Hodgkin and non-Hodgkin lymphomas.

Pulmonary Rehabilitation

Radiology – High Technology Prior approval is required for all high technology radiology including: • Magnetic resonance imaging (MRI) • Computed tomography (CT) scan • Positron emission tomography (PET) scan Notes: • High technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval. • Prior approval requests for the radiology service listed above are filed with Blue Cross VT, not Carelon

Reproductive Services Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI).

Residential Treatment Center Care (Outpatient) Prior approval is required for any condition.

Sperm/Egg Storage
Prior Approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.

Stem Cell Transplants (Blood or Marrow)

2025 FEP Blue Focus; effective on January 1, 2025 Updated: December 2, 2024 All services require prior approval. Note, these must be performed in a transplant program designated as a Blue Distinction Center for Transplants.

Clinical trials for certain blood or marrow stem cell transplants, contact the FEP customer service team for details as some benefits are only available for specific type of clinical trial.

For the purposes of the blood or marrow stem cell clinical trial transplants covered, a clinical trial is a research study whose protocols has been reviewed and approved by the Institutional Review Board (IRB) of the Blue Distinction Center for Transplants where the procedure is performed.

Stereotactic Radiosurgery Prior approval 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.

Stereotactic Body Radiation Therapy

Surgical Services (Inpatient or Outpatient Settings) The surgical services listed below require prior approval when care is provided in an inpatient or outpatient setting. Precertification is required for the inpatient hospital stay. • Breast Reduction or augmentation not related to the treatment of cancer • Obesity – Procedures to treat serve obesity o Note: Benefits for surgical treatment of severe obesity -performed on an inpatient or outpatient basis – are subject to the pr-surgical requirements listed in the FEP Bariatric Medical Policy. Benefits are only available for the surgical treatment of severe obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) Surgery. • Oral maxillofacial surgeries/surgery on the jaw, cheek, lips, tongue, floor and roof of the mouth and related procedures. • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ) • Orthopedic procedures – hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation. • Reconstructive Surgery – for conditions other than breast cancer. • Rhinoplasty • Septoplasty • Varicose vein treatment

Transplants Prior approval is required for transplant travel, the procedure and if benefits require, the transplant program; precertification is required for inpatient care. Benefits for certain transplants are limited to designated transplant centers or programs or if not available, at a preferred facility with a Medicare- Approved Transplant Program for the type of transplant anticipated if Medicare has an approval program for the type of transplant.

2025 FEP Blue Focus; effective on January 1, 2025 Updated: December 2, 2024 *See Stem Cell Transplants above for specifics related to that transplant.

Special Prior Approval situations related to Coordination of Benefits (COB)

The table below provides the special situations regarding prior approval and pre-certification when another healthcare insurance is the primary payor:

Service Type Primary Payor Pre- certification Prior Authorization Inpatient hospital admission • Medicare Part A or • Other healthcare insurance No Not applicable Medicare hospital benefits exhausted and member does not want to use their Medicare lifetime reserve days • Medicare Part A - benefits not provided Yes Not applicable Residential treatment center admission- inpatient • Medicare Part A or • Other healthcare insurance Yes Not applicable Residential treatment center – outpatient care • Medicare Part B or • Other healthcare insurance Not applicable Yes