The Federal Employee Program (FEP) is a nationwide Federal Employees Health Benefits (FEHB) program administered through local Blue Cross and Blue Shield Association plans. This program should not be confused with HMSA's Federal Employees Health Benefits (FEHB) program (coverage code 87). The FEP FEHB membership cards are identified by enrollment codes 104, 105, and 106 for the FEP Blue Standard Option and 111, 112, and 113 for the FEP Blue Basic Option. FEP Blue Focus Option enrollment codes are 131, 132, and 133.
FEP Blue Focus Option members must use preferred providers for all medical care (with some exceptions, such as emergency care).
Providers should always verify member eligibility via HHIN+ under Blue Exchange or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Information on member benefits and claims status is also available on HHIN+ or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Sex-Trait Modification
Effective January 1, 2026, FEP will no longer cover chemical or surgical services intended to modify sex traits (gender-affirming care).
If members are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which they received coverage under the 2025 Plan brochure, they may seek an exception to continue care for that treatment. If members have questions about the exception process, they should contact customer service using the phone number listed on the back of their ID card. If they disagree with our decision, they can refer to Section 8 of the brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria.
Pre-certification
FEP requires precertification prior to your inpatient admission. Precertification may be required for members despite having another insurance carrier primary to FEP.
When FEP is the secondary insurance carrier and the patient's primary insurance limits are met, FEP becomes their primary insurance carrier.
If you have an emergency inpatient admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily functions, you, your representative, the physician or the hospital must call us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.
We will reduce our benefits for the inpatient hospital stay by $500 even if you have obtained prior approval for the services or procedure being performed during the stay, if no one contacts us for precertification. If your stay is not medically necessary, we will not provide benefits for inpatient hospital room and board or inpatient physician care. We will only pay for covered medical services and supplies that are otherwise payable on an outpatient basis.
Medical Admissions
To get precertification before an inpatient hospital admission, please call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Behavioral Health Admissions
Prior approval is no longer required for outpatient professional, or outpatient facility care for mental health and substance abuse treatment.
Inpatient mental health or alcohol and substance abuse services require precertification. A provider with the appropriate clinical background (e.g., M.D., Ph.D., Psy.D., C.S.W., C.S.A.C. or R.N.) and who is knowledgeable about the patient's clinical condition should call or fax HMSA's Behavioral Health Services QUEST Integration (Carelon Behavioral HealthSM) to open a case file for the patient, arrange an initial evaluation, and precertify any services. Be sure to have the following information available:
- The patient's name and FEP member ID number.
- The name of the facility/program to which the member will be admitted.
- The name and provider number of the admitting psychiatrist or psychologist.
- The date of the proposed admission.
- Clinical information about the patient, including the diagnosis and proposed treatment regimen.
We'll give a verbal precertification at the time of the initial phone call for an admission requested by a specially contracted provider. FEP/HMSA will send a follow-up letter within seven working days with the following information:
- A precertification number.
- The number of inpatient days approved.
- The effective date of the precertification.
- Please note that a precertification from FEP/HMSA confirms that the services are necessary and appropriate but doesn't guarantee the availability of benefits.
To precertify ongoing services, a provider with the appropriate clinical background (e.g., M.D., Ph.D., Psy.D., C.S.W., C.S.A.C. or R.N.) should make subsequent calls to HMSA with clinical data to discuss the patient's status.
Prior Approval
The following services require prior approval for members with FEP Blue Focus Option.
- Gene therapy and cellular immunotherapy, including CAR-T and T-Cell receptor therapy;
- Medical benefit drugs – We require prior approval for certain drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs for a list of these drugs;
- Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate care of a medical emergency or accidental injury does not require prior approval;
- Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments;
- Genetic testing – Prior approval for genetic testing will be 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 a 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 your genetic test requires prior authorization, call the customer service number on the back of your ID card before scheduling;
- Surgical services –The surgical services on the following list require prior approval and when care is provided in an inpatient setting, precertification is required for hospital stay.
- Procedures to treat severe obesity;
- Breast reduction or augmentation not related to treatment of cancer;
- Oral maxillofacial surgeries/ surgery on the jaw, cheeks, lips, tongue, and the roof and floor 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 navigation;
- Reconstructive surgery for conditions other than breast cancer;
- Rhinoplasty;
- Septoplasty;
- Varicose vein treatment;
- Proton beam therapy – Prior approval is required for all proton beam therapy services except for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas;
- 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;
- Reproductive services – Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI);
- Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility;
- Cardiac rehabilitation;
- Cochlear implants;
- Residential treatment center care for any condition
- Prosthetic devices (external) including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis
- Pulmonary rehabilitation
- Radiology, high technology including:
- Magnetic resonance imaging (MRI);
- Computed tomography (CT) scan;
- Positron emission tomography (PET) scan;
*Note: High technology radiology related to immediate care of medical emergency or accidental injury does not require prior approval.
- Specialty durable medical equipment (DME), rental or purchase to include:
- Specialty hospital beds;
- Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies;
- Transplant – If you travel to a Blue Distinction Center for Transplants, we reimburse up to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for you and your traveling companions) if you live 50 miles or more from the facility;
- Blood or marrow stem cell transplants 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 us at the customer service telephone number for specific conditions covered;
- Organ/tissue transplants – Benefits for certain transplants are limited to designated transplant centers or programs.
- Transplant travel – If you travel to a Blue Distinction Center for Transplants, we reimburse up to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for you and your traveling companions) if you live 50 miles or more from the facility;
- Prescription drugs and supplies – Certain prescription drugs and supplies, including medical foods administered orally, require prior approval. Contact CVS Caremark, our Pharmacy Program administrator to request prior approval or to obtain a list of drugs and supplies that require prior approval.
To get preauthorization for the services listed above, call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
To get preauthorization for select prescription drugs, call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii's Retail Pharmacy.
Severe Obesity
Benefits for procedures to treat severe obesity are available when the member meets the clinical criteria in our Bariatric medical policy at https://www.fepblue.org/legal/policies-guidelines for any initial and subsequent surgery (prior approval required).
Dental and Vision Benefits
FEP Blue Focus Option dental plan does not cover routine dental care. We provide benefits for service, supplies or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. Treatment of an accidental dental injury is when you receive care within 72 hours after an accidental injury.
Information on covered dental benefits is available at www.fepblue.org or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
FEP Blue Focus Option vision benefits allows eye examinations or visits related to a specific medical condition. Diagnostic testing and treatment, such as:
- Nonsurgical treatment for amblyopia and strabismus, for children from birth though age 21;
- Lab, x-ray, and other diagnostic tests performed or ordered by your provider;
- Refractions, only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident.
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
- To correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery;
- If the condition can be corrected by surgery, but surgery is not an appropriate option due to age or medical condition;
- For the nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21.
Information on eligibility and benefits is available on HHIN+ or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Physical, Occupational, and Speech Therapy Benefits
Physical therapy benefits for FEP Blue Focus Option plans include outpatient physical, occupational, and speech therapy limited to 25 visits total for all three services per person per year. FEP does not require authorization through Evolent. Benefit information is available on www.fepblue.org or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Claims Filing Information
For services in Hawaii, please submit claims on a CMS-1500 or UB-04 form, as appropriate, to the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Information on eligibility, benefits, and claims status is available on HHIN+ or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.
Provider Fee schedules are available on HHIN+.
How to Submit a Provider Reconsideration
Please mail your request for reconsideration in writing, along with any additional information, to the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii. Attn: Reconsiderations.
FEP will notify you of its decision no later than 30 days after receiving all documentation reasonably needed to render a decision.
If FEP decides in your favor, payment will be made. If the determination isn't in your favor, the letter will explain your rights to an appeal.
