2015 FEP benefits feature BRCA mutation testing for adult males, updated guidelines for transplants

New coverage for BRCA mutation testing is among the Federal Employee Program benefit changes for 2015. We've outlined other benefit changes for FEP members below.

The following changes apply to both the Standard Option and Basic Option benefit plans for services provided on or after Jan. 1, 2015:

Preventive care

• We now provide preventive care benefits for genetic counseling and evaluation services related to preventive BRCA testing for males age 18 and older. The males must have a family history associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes. Benefits are limited to one BRCA test per lifetime. (Previously, preventive care benefits for these services were not available for male members.)
• Preventive care benefits are now available for BRCA testing in males and females with a family history of both breast and fallopian tube cancer or breast and primary peritoneal cancer among first- and second-degree relatives. (Previously, the family history criteria for BRCA testing did not include the presence of fallopian tube or primary peritoneal cancer with breast cancer.)
• Prior approval for all BRCA testing is required before the test is performed, whether it is performed for preventive or diagnostic reasons. For preventive BRCA testing, the member must also receive genetic counseling and evaluation services before the test is performed. (Previously, BRCA testing was not subject to these requirements.)
• We now provide preventive care benefits to screen for diabetes mellitus in adults. (Previously, preventive benefits were available for related screening only when performed as part of a metabolic panel.)
• Preventive care benefits are now available for hepatitis C screening in adults.
• We now provide preventive care benefits for low-dose CT screenings for lung cancer in adults ages 55 to 80 with a history of tobacco use.

Women’s care

• Benefits for tocolytic therapy and related services are now limited to those services provided on an inpatient basis. (Previously, benefits were also available for in-home services.)
• We’ve updated our prescription drug benefits for tamoxifen and raloxifene. These generic drugs are now covered in full when they’re obtained from a Preferred pharmacy to reduce breast cancer risk for women ages 35 or older who have not been diagnosed with any form of breast cancer.

Blood, stem cell and organ transplants

• We now provide benefits for certain allogeneic blood or marrow stem cell transplants limited to select diagnoses and stages. This includes those transplants that are performed in a facility accredited by the Foundation for the Accreditation of Cellular Therapy, a Blue Distinction^® Center for Transplants or a cancer research facility. (Previously, these benefits were limited to transplant procedures performed at a Blue Distinction Center for Transplants.)
• We now reimburse members for eligible travel expenses related to covered transplants performed at designated Blue Distinction Centers for Transplants. The member must live 50 miles or more from the facility, and the reimbursement is subject to certain criteria.
• We provide benefits for covered organ transplants only when they are performed in facilities with a Medicare-approved transplant program for the type of transplant anticipated. This guideline does not apply to facilities where Medicare does not maintain an associated approved program. (Previously, benefits for organ transplants were not subject to this requirement.)
• Benefits are now available for implantation of an artificial heart as a bridge to transplant or destination therapy.
• Benefits for simultaneous liver and kidney transplants, single lung transplants, double lung transplants and pancreas transplants performed at Blue Distinction Centers for Transplants are now limited to adult members.

Medical facilities

• When members use a designated Blue Distinction Center for certain inpatient bariatric, hip, knee or spine surgeries, cost shares have been reduced to $150 per admission under the Standard Option and to $100 per day ($500 maximum) under the Basic Option.
• When members use a facility designated as a Blue Distinction Center for Bariatric Surgery for outpatient laparoscopic gastric banding surgery, the following copayments will now apply: $100 per day per facility under Standard Option and $25 per day per facility under Basic Option. Regular benefit levels apply to charges for the professional services, including surgery and anesthesia.
• When emergency room services related to an accidental injury or medical emergency are performed by Nonpreferred professional providers in a Preferred hospital, members are responsible for their cost share for those services. They’re also responsible for any difference between our allowance and the billed amount.
• We now provide benefits for outpatient facility mental health and substance abuse services when performed and billed by residential treatment centers.

Wellness incentives

Members who complete a Blue Health Assessment health risk questionnaire are eligible for a $50 health account to be used for qualified medical expenses. (Previously, members were eligible for a $40 health account. Please encourage your FEP patients to complete the Blue Health Assessment.)

The following changes only apply to Standard Option members for services provided on or after Jan. 1, 2015:

Medical facilities

• We’ve reduced the copayment for accidental injury or medical emergency care provided at a Preferred urgent care center to $30 per visit. (Previously, the copayment was $40 per visit.)
• The cost share for an inpatient admission to a nonparticipating hospital or other covered facility for mental health and substance abuse services is now 35 percent of the plan allowance and any remaining balance after the plan’s payment. (Previously, members were also responsible for a $350 per admission copayment for these services.)
• The cost chare for inpatient professional mental health and substance abuse services is now 35 percent of the plan allowance for participating and nonparticipating providers. When services are performed by nonparticipating providers, members are also responsible for the difference between the plan allowance and the billed amount. (Previously, members were also required to meet their calendar-year deductible for these services.)
• We now provide benefits for inpatient admissions to residential treatment centers for mental health and substance abuse services only for Standard Option members who have Medicare Part A coverage as their primary insurance.  (Previously, there were no benefits for this type of inpatient admission.)

The following changes only apply to Basic Option members for services provided on or after Jan. 1, 2015:

• For cardiovascular monitoring services performed by a Preferred professional or facility provider, a copayment of $40 is now applied. (For standard electrocardiograms, there is no copayment.)
• We’ve reduced the copayment for accidental injury or medical emergency care provided at a preferred urgent care center to $35 per visit. (Previously, the copayment was $50 per visit.)