Federal Employee Program (FEP) services requiring prior authorization or notification
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Lists Federal Employee Program (FEP) services that require prior authorization or prior notification across plan types (Standard & Basic and FEP Blue Focus); affects providers and facilities submitting authorization/notification for covered services.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Prior Notification
Prior authorization / notification listing
This list indicates which Federal Employee Program (FEP) services require prior authorization (marked X) or prior notification by plan type (Standard & Basic vs FEP Blue Focus).
ALL of the following
Genetic testing
- BRCA screening or diagnostic testing — Standard & Basic: X; FEP Blue Focus: X
- Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing — Standard & Basic: X; FEP Blue Focus: X
- Genetic testing for the diagnosis and/or management of an existing medical condition — Standard & Basic: (no X); FEP Blue Focus: X
Surgical services
- Outpatient surgery for morbid obesity — Standard & Basic: X; FEP Blue Focus: (no X)
- Outpatient surgical correction of congenital anomalies — Standard & Basic: X; FEP Blue Focus: (no X)
- Outpatient surgery to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth — Standard & Basic: X; FEP Blue Focus: (no X)
- Gender reassignment surgery — Standard & Basic: X; FEP Blue Focus: (no X)
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the TMJ — Standard & Basic: (no X); FEP Blue Focus: X
Orthopedic procedures
- Orthopedic procedures (hip, knee, ankle, spine, shoulder) using computer-assisted musculoskeletal surgical navigation — Standard & Basic: (no X); FEP Blue Focus: (no X)
Other outpatient & specialty services
- Outpatient intensity‑modulated radiation therapy (IMRT) — Standard & Basic: X; FEP Blue Focus: (no X)
- Prosthetic devices (external), including microprocessor controlled limb prosthesis and electronic/externally powered prosthesis — Standard & Basic: (no X); FEP Blue Focus: X
- Pulmonary rehabilitation — Standard & Basic: (no X); FEP Blue Focus: X
- Radiology, high technology (MRI, CT, PET) — Standard & Basic: (no X); FEP Blue Focus: X (note: excludes high‑technology radiology related to immediate care of a medical emergency or accidental injury)
Durable medical equipment & related services
- Specialty durable medical equipment (DME) (rental or purchase) including specialty hospital beds, deluxe wheelchairs, power wheelchairs and mobility devices and related supplies — Standard & Basic: (no X); FEP Blue Focus: X
Advanced therapies and transport
- Gene therapy and cellular immunotherapy (for example CAR‑T and T‑Cell receptor therapy) — Standard & Basic: X; FEP Blue Focus: X
- Air ambulance transport (non‑emergent) — Standard & Basic: (no X); FEP Blue Focus: X
Transplant-related
- All covered organ/tissue transplants except kidney and cornea — Standard & Basic: (no X); FEP Blue Focus: (no X)
- Blood or marrow stem cell transplants — Standard & Basic: (no X); FEP Blue Focus: (no X)
- Transplant travel — Standard & Basic: X; FEP Blue Focus: (no X)
Sleep, behavioral and other services
- Outpatient sleep studies performed outside the home — Standard & Basic: (no X); FEP Blue Focus: (no X)
- Applied behavior analysis (ABA) — Standard & Basic: (no X); FEP Blue Focus: (no X)
Maternity care (prior notification)
- Maternity Care — Standard & Basic: (no X); FEP Blue Focus: X (requires prior notification)
Coding and Numeric Thresholds
| No codes listed |
Provider Actions — Prior Authorization Highlights
Genetic testing — BRCA and large genomic rearrangements require prior authorization
BRCA screening or diagnostic testing and large genomic rearrangements of the BRCA1 and BRCA2 genes require prior authorization for both Standard & Basic and FEP Blue Focus plan types; other genetic testing flags vary by plan.
- BRCA screening or diagnostic testing, Standard & Basic = X; FEP Blue Focus = X.
- Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing, Standard & Basic = X; FEP Blue Focus = X.
IMRT (outpatient) requires prior authorization for Standard & Basic
Outpatient intensity‑modulated radiation therapy (IMRT) is marked as requiring prior authorization for the Standard & Basic plan (FEP Blue Focus is not marked).
- Outpatient intensity‑modulated radiation therapy (IMRT), Standard & Basic = X.
- Outpatient intensity‑modulated radiation therapy (IMRT), FEP Blue Focus = .
Gene therapy / cellular immunotherapy require prior authorization
Gene therapy and cellular immunotherapy (for example, CAR‑T and T‑Cell receptor therapy) are listed as requiring prior authorization for both Standard & Basic and FEP Blue Focus.
- Gene therapy and cellular immunotherapy, for example CAR‑T and T‑Cell receptor therapy, Standard & Basic = X; FEP Blue Focus = X.
Transplant travel requires prior authorization for Standard & Basic
Transplant travel is indicated as requiring prior authorization for the Standard & Basic plan (FEP Blue Focus is not marked).
- Transplant travel, Standard & Basic = X.
- Transplant travel, FEP Blue Focus = .
Definitions and Example Therapies
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.