Coverage expanded for licensed medical practitioners in 2014 FEP benefits

New coverage for medical practitioners and BRCA mutation testing are among the Federal Employee Program^® benefit changes for 2014. We've outlined other benefit changes for FEP members below.

The following changes apply to both the Standard and Basic Option benefit plans for services provided on or after Jan. 1, 2014:

• Any licensed medical practitioner is eligible for benefit coverage for his or her services if those services are performed within the scope of that license, as required by Section 2706(a) of the Public Health Service Act. This coverage is subject to documented criteria. Previously, benefits for certain medical practitioners were limited to services performed in medically underserved areas.
• New preventive care benefits are available for BRCA mutation testing for adult females when certain criteria are met. Benefits for both preventive and diagnostic testing are limited to one BRCA test per lifetime.
• Two tiers of specialty drugs are now available: Tier 4 includes preferred specialty drugs, and Tier 5 includes non-preferred specialty drugs. Previously, all specialty drugs were included in Tier 4.
• Benefits will be provided in full for Vitamin D supplements for adults age 65 and older. These supplements must be prescribed by a physician and obtained from a preferred retail pharmacy.
• Insulin and diabetic supplies must be obtained from a retail pharmacy or, for Standard Option only, from the Mail Service Prescription Drug Pharmacy Program. This requirement does not apply to members who have Medicare Part B as their primary insurance.
• Benefits are available for cancer patients to purchase wigs if they’ve experienced hair loss due to their treatments. This benefit is limited to a maximum of $350 for one wig per lifetime. (Previously this benefit only applied to hair loss due to chemotherapy for the treatment of cancer.)
• When a non-participating provider bills for drugs, we will consider the Medicare Part B Average Sale Price in the calculation to determine our plan allowance.
• Benefits are no longer available for heart-lung transplants when performed at Blue Distinction Centers for Transplants^®.

These changes apply only to Standard Option members for services incurred on or after Jan. 1, 2014:

• The maximum number of home nursing care visits allowed has increased to 50 visits per calendar year.
• The copayment for Tier 2 preferred, brand-name drugs purchased through the FEP Mail Service Prescription Drug Program is $80 per prescription for up to a 90-day supply.
• The copayment for Tier 3 non-preferred brand-name drugs purchased through the FEP Mail Service Prescription Drug Program is $105 per prescription for up to a 90-day supply.
• New prescriptions of Tier 4 or Tier 5 specialty drugs may be filled at a preferred retail pharmacy or through the FEP Specialty Drug Pharmacy Program. Members must use the FEP Specialty Drug Pharmacy Program for any refills of the same specialty drug. FEP will cover supplies of up to 30 days for the first three fills of the same Tier 4 or Tier 5 prescription. The member may receive supplies of up to 90 days beginning with the fourth fill.
• The copayment for Tier 4 preferred specialty drugs dispensed by the FEP Specialty Drug Pharmacy Program is $35 for up to a 30-day supply, and $95 for a 90-day supply.
• Members pay 30 percent of the FEP plan allowance for Tier 5 non-preferred specialty drugs dispensed by a preferred retail pharmacy.
• The copayment for Tier 5 non-preferred specialty drugs dispensed by the FEP Specialty Drug Pharmacy Program is $55 for up to a 30-day supply, and $155 for up to a 90-day supply.

 The following changes apply only to Basic Option members for services incurred on or after Jan. 1, 2014:

• Coinsurance for non-preferred, brand-name drugs purchased at preferred retail pharmacies will apply toward the out-of-pocket maximum for the annual catastrophic protection.
• The copayment for surgical procedures performed outside the office setting is $200 per performing surgeon.
• The copayment for an inpatient admission to a preferred facility is $175 per day, up to a maximum of $875 for unlimited days.
• The copayment for a maternity inpatient admission to a preferred facility is $175.
• The copayment for diagnostic tests such as EEGs, ultrasounds and X-rays performed by a preferred professional provider is $40.
• The copayment for diagnostic tests and radiological services is $100 when performed by a preferred professional provider. These services include bone density tests, CT scans, MRIs, PET scans, angiographies, genetic tests, nuclear medicine and sleep studies.
• The copayment for outpatient diagnostic testing and treatment services is $150 when performed at a preferred, member or non-member facility. These services include angiographies, bone density tests, CT scans, MRIs, PET scans, genetic testing, nuclear medicine and sleep studies.
• The copayment for outpatient diagnostic testing services such as EEGs, ultrasounds and X-rays is $40 per day per preferred, member or non-member facility.
• Benefits for up to 10 acupuncture visits per year are now available. These services must be performed by preferred providers acting within the scope of their license or certification in the state where the services are provided. Previously, benefits for acupuncture were only available when provided by a physician.
• The copayment for neurological testing is $40 when performed by a preferred professional provider.
• The FEP copayment for Tier 2 preferred, brand-name drugs purchased at a preferred retail pharmacy is $45 for up to a 30-day supply.
• Members pay 50 percent of the FEP plan allowance or a minimum $55 copayment for Tier 3 non-preferred, brand-name drugs purchased at a preferred retail pharmacy for up to a 30-day supply.
• New prescriptions of Tier 4 or Tier 5 specialty drugs may be filled at a preferred retail pharmacy or through the FEP Specialty Drug Pharmacy Program. The member must use the FEP Specialty Drug Pharmacy Program for any refills of the same specialty drug. FEP will cover up to a 30-day supply for the first three refills of the same Tier 4 or Tier 5 prescription. The member may receive up to a 90-day supply beginning with the fourth refill.
• The FEP copayment for Tier 4 preferred specialty drugs dispensed by a preferred retail pharmacy is $60. Benefits are limited to one purchase of up to a 30-day supply for each prescription filled.
• The FEP copayment for Tier 5 non-preferred specialty drugs dispensed by a preferred retail pharmacy is $80. Benefits are limited to one purchase of up to a 30-day supply for each prescription filled.
• The FEP copayment for Tier 4 preferred specialty drugs dispensed through the Specialty Drug Pharmacy Program is $50 for up to a 30-day supply and $140 for up to a 90-day supply.
• The copayment for Tier 5 non-preferred specialty drugs dispensed through the FEP Specialty Drug Pharmacy Program is $70 for up to a 30-day supply and $195 for up to a 90-day supply.