Blue cross blue shield federal prior authorization

Health insurance can be complicated—especially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). We’ve provided the following resources to help you understand Anthem’s prior authorization process and obtain authorization for your patients when it’s required.

Effective 1/1/2022, our Blue Cross and Blue Shield of Texas (BCBSTX) Federal Employee Program (FEP®) participants will have some changes to their prior authorization requirements and benefits.

Prior Authorization Updates

  • Kidney transplants will now require prior approval and are now part of the Blue Distinction Centers for Transplants® (BDCT) Program.
  • Pancreas transplants continue to require prior approval but are removed from the BDCT program
  • Air Ambulance (non-emergent) transport from one facility to another requires prior approval and falls under the No Surprise Billing Act 
    Blue cross blue shield federal prior authorization
    .

Benefit Changes

Be sure to check eligibility and benefits through FEP Customer Service or Availity® for specifics on FEP member benefits. The following have changes to benefits:

Prior Approval

As part of our Patient Safety and Quality Monitoring (PSQM) program (see above), you must make sure your physician obtains prior approval for certain prescription drugs and supplies in order to use your prescription drug coverage. In providing prior approval, we may limit benefits to quantities prescribed in accordance with generally accepted standards of medical, dental, or psychiatric practice in the United States. Prior approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077. You can also obtain the list and forms through our website at www.fepblue.org. Please read Section 3 for more information about prior approval.

Notes:
  • Updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
     
  • If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.
     
  • It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work with your physician to obtain prior approval renewal in advance of the expiration date.

FEP® to eliminate restrictions on prescription drug refills, waive pre-authorization, deductibles and copays for diagnostics, treatment

WASHINGTON – The Blue Cross and Blue Shield Federal Employee Program® (FEP®) announced today that it will waive cost-sharing for coronavirus diagnostic testing, waive prior authorization requirements for treatment and take other steps to enhance access to care for those needing treatment for COVID-19 to ensure its members can swiftly access the right care in the right setting during the outbreak. 

These changes, which have been approved by the Office of Personnel Management, will ensure that nearly 6 million federal employees, retirees and their families have comprehensive, accessible care. They include: 

  1. FEP will waive prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with Centers for Disease Control and Prevention (CDC) guidance if diagnosed with COVID-19. 
  2. Similarly, FEP will waive any copays or deductibles for diagnostic tests or treatment that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19.   
  3. FEP will increase access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications. FEP will also encourage members to use 90-day mail order benefit. 
  4. FEP will also eliminate any cost share for prescriptions for up to a 14-day supply.  
  5. FEP will waive copays for telehealth services related to COVID-19.  

“As Americans continue to monitor the coronavirus outbreak, one thing they should not be concerned with is whether Blue Cross and Blue Shield will be there for them,” said William A. Breskin, senior vice president of government programs for the Blue Cross Blue Shield Association. “We take our members’ health very seriously and want to make sure there are no barriers to their seeking appropriate care if they become sick.” 

FEP and Blue Cross and Blue Shield (BCBS) companies are following CDC prevention guidelines and other federal recommendations and will continue to support and protect the health and well-being of its members, their families and the community. These actions will apply to all FEP members of the 36 U.S. and Puerto Rico-based BCBS companies, including those members located overseas, when applicable.

For more information on FEP’s policy changes, please visit www.fepblue.org for details on the expansion of benefits and services. Members can also call the National Information Center at 1-800-411-BLUE (2583). If you are not an FEP member and have questions about your health plan, please contact your local BCBS Company: bcbs.com/memberservices.