2026 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Standard and Basic Options Form

2026 FEP Service Benefit plans Standard Option and Basic Option; effective on January 1, 2026 Updated: November 5, 2025 2026 Federal Employee Program (FEP) Prior Approval/Pre-Certification List for: • Federal Employee Health Benefit Standard Option or • Postal Employee Health Benefit Standard Option or • Federal Employee Health Benefit Basic Option or • Postal Employee Health Benefit Basic Option Please note: There is a separate Prior Approval/Pre-Certification list for the FEP Blue Focus product 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. Services requiring Pre-Certification: • Inpatient hospital admissions • Inpatient residential treatment centers • Skilled nursing facilities

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.

Gene Therapy and Cellular Immunotherapy Prior approval is required for all gene therapy and cellular immunotherapy, for example CAR-T and 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 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.

Hearing Aids Prior approval is required to receive coverage for hearing aids.

2026 FEP Service Benefit plans Standard Option and Basic Option; effective on January 1, 2026 Updated: November 5, 2025 Medical Benefit 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.

Organ/Tissue Transplants Prior approval required for both the procedure and the facility.

When using a Blue Distinction Center for Transplants, prior approval is also required for travel benefits.

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.

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.

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

Sleep Studies (Outpatient Facility Based) Prior approval is 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 in the patient’s home.

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) All services require prior approval and must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT) or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility.

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

2026 FEP Service Benefit plans Standard Option and Basic Option; effective on January 1, 2026 Updated: November 5, 2025 craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.

Stereotactic Body Radiation Therapy

Surgical Services
The surgical services listed below require prior approval. This requirement applies to both the physician services and the facility services. • Surgery for elective non-urgent orthopedic procedures; hip, knee, and spine • Surgery for severe obesity o Note- benefits for the surgical treatment of severe obesity – performed on an inpatient or outpatient basis – are subject to pre-surgical requirements listed in our medical policy at www.fepblue.org/leg/policies-guidelines • Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue roof and floor of mouth except when care is provided within 72 hours of the accidental injury.