Provider Central

We’ll make the following changes to all our FEP plans:

• New Medicare Prescription Drug Program (MPDP)
  This new pharmacy benefit program allows eligible members with Medicare Part A and/or Part B to get additional approved prescription drugs in some tiers and pay lower out-of-pocket costs for higher-cost drugs. The formularies are available at fepblue.org/medicarerx.
• Expanded access to mental health care
  We’ll now cover marital and family counseling for all members.

New Benefits

Enhanced reproductive care coverage

Starting January 1, 2024, we’ll cover:

• Specific artificial insemination procedures.
• Associated prescription drugs for covered services. Members must receive prior approval for artificial insemination.
• Up to three annual drug cycles for in vitro fertilization (IVF) for members diagnosed with infertility. Members must receive prior approval and buy prescriptions through our pharmacy programs.

Gender-affirming care

In 2024, we’ll cover:

• Breast augmentation for male-to-female gender-affirming care.
• A mastectomy beginning at the age of 16 for female-to-male gender-affirming care.
• Certain facial surgeries for gender affirming care and no limit on medically necessary gender-affirming surgical services. Previously, we did not cover facial gender-affirming surgery, and we limited covered procedures to once per lifetime.
• We’ll only require six months of continuous hormone therapy appropriate to the member’s gender identity, unless medically contraindicated. Previously, we required 12 months of continuous hormone therapy.

Genetic testing

We will cover medically necessary genetic testing for members who may be at high-risk for certain conditions. Members must receive prior approval.

Prior approval changes

The following services will no longer require prior approval:

• Intensity-modulated radiation therapy (IMRT).
• Proton beam therapy (for members aged 21 and younger, or when care is related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; and Hodgkin’s and non-Hodgkin’s lymphomas).
• Stereotactic radiosurgery (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, paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations).
• Surgical treatment for congenital anomalies.

The following medications will require prior approval when covered under the member’s medical benefits:

Other important changes

• Bariatric surgery coverage is now listed in the FEP medical policy.
• Residential treatment center (RTC)
  We no longer require the member’s written consent to participate in a case management program before they can be admitted for inpatient care provided by an RTC.
• Stem cell transplants and clinical trials
  FEP has expanded coverage and made changes to clinical trial requirements. Please go to FEPblue.org to review medical policies and Plan specific brochures for specific information.

Hearing aids require prior approval for coverage. Previously prior approval was not required.

For members who do not have primary Medicare Part A, we no longer require a Skilled Nursing Facility (SNF) signed consent form agreeing to enrollment and active participation in case management during a SNF stay before admission.

• Prior approval for kidney transplants will be required.
• There are no calendar year limitations for stays at RTCs that are medically necessary. Previously, coverage was limited to 30-day inpatient stay per calendar year.

As always, please visit FEPblue.org to review FEP Medical Polices and Plan specific brochures for all-inclusive list of benefits and prior authorization requirements.