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 for all inpatient hospital admissions. 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.
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 - Commercial, FEP, Fed 87 (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 Standard Option.
- Gene therapy and cellular immunotherapy, for example 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;
- Outpatient sleep studies performed outside the home – Prior approval is required for sleep studies performed in a provider’s office, sleep center, clinic, any type of outpatient center, or any location other than your home;
- 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 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 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;
- Hearing aids – Prior approval is required to receive coverage for hearing aids;
- Surgical services - The surgical services on the following list require prior approval for care performed by Preferred, Participating/Member, and Non-participating/Non-member professional and facility providers:
- Surgery for elective non-urgent orthopedic procedures: hip, knee, and spine;
- Surgery for severe obesity;
- Note: Benefits for the surgical treatment of severe obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed in our medical policy at www.fepblue.org/legal/policies-guidelines.
- Surgery needed to correct accidental injuries to jaw, cheeks, lips, tongue, and the roof and floor of the mouth except when care is provided within 72 hours of the accidental injury;
- 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), intravaginal insemination (IVI), and assisted reproductive technologies (ART).
- Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
- Organ/tissue transplants – Prior approval is required for both the procedure and the facility. Contact us at the customer service phone number listed on the back of your ID card before obtaining services. We will request the medical evidence we need to make our coverage determination. We will consider whether the facility is approved for the procedure and whether you meet the facility’s criteria.
- Some organ transplant procedures;
- Some blood or marrow stem cell transplants 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 us at the customer service phone number on the back of your ID card for information or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage determination;
- Transplant travel – We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant for the member and companions. If the transplant recipient is age 21 or younger, we pay up to $10,000 for eligible travel costs for the member and companions. Reimbursement is subject to IRS regulations;
- Prescription drugs and supplies – Certain prescription drugs and supplies 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;
- Medical Foods covered under the pharmacy benefit 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
Prior approval is required for outpatient surgery for severe obesity, except – under FEP Blue Standard Option and FEP Blue Basic Option only – when Medicare or Other Commercial Coverage (OCC) is the primary payer.
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
Dental benefits on FEP Blue Standard Option plans cover preventive dental care and some other non-routine services. Predetermination/preauthorization is not required for dental benefits. 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.
Vision benefits under the FEP Blue Standard Option plan include eye examinations related to a specific medical condition and one pair of eyeglasses, replacement lenses, or contact lenses per incident to correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery. 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 Standard Option plans include outpatient physical, occupational, and speech therapy limited to 75 visits total for all three services per person per year. FEP doesn't 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.
