Here’s a look at Federal Employee Program^® Service Benefit Plan coverage changes for 2017

Autism spectrum disorder coverage

We now provide benefits for applied behavior analysis for the treatment of an autism spectrum disorder. Prior approval is required for applied behavior analysis and related services, including assessments, evaluations and treatment. Benefits aren’t available for applied behavior analysis for any other condition. Previously, benefits weren’t provided for applied behavior analysis services. For benefit questions, call FEP Customer Service at 1-800-482-3600. For prior authorization, call New Directions Behavioral Health Inc. at 1-800-342-5891.

Transgender benefit coverage

We now provide benefits for gender reassignment surgery, limited to once per lifetime, for adult members age 18 or older. Prior approval is required. Previously, benefits were not available for gender reassignment surgery.

Preventive care coverage

We’re expanding the eligibility criteria for BRCA-related testing for members with a first- or second-degree relative diagnosed with pancreatic or prostate cancer.

We now provide annual preventive care benefits for screening mammography using digital technology. Previously, digital technology was only covered for diagnostic mammograms.

Vision benefit change

We now provide benefits for the nonsurgical treatment of amblyopia and strabismus for children from birth through age 21. Previously, benefits were provided for children from birth through age 18.

Sleep study benefit change

We now require prior approval for sleep studies performed in a location other than the
member’s home.

Member incentive program changes

Members who qualify for the Diabetes Management Incentive Program will now receive a maximum incentive of up to $100 for their wellness account. We have also reduced the number of steps required to earn the incentive.

The WalkingWorks^® wellness program was eliminated due to changes in the tracking activities technology.

Prescription drug benefit changes

Certain FDA-approved drugs that have multiple generic equivalent or alternative medications may be excluded from the Standard Option and Basic Option formularies. If the member purchases a drug that is excluded from the formulary, he or she will be responsible for the full cost of that drug. Previously, all FDA-approved drugs were covered under prescription drug benefits, with the exception of some lifestyle drugs.

We now limit benefits for certain self-injectable drugs obtained from a source other than a pharmacy. Medical benefits are provided for a once-per-lifetime dose. Benefits for additional doses are available only when the drug is dispensed by a pharmacy under the pharmacy benefit. This limitation doesn’t apply to members with primary coverage under Medicare Part B. Previously, benefits were available for these drugs through medical benefits without limit. Basic Option members must use a preferred pharmacy.

Overseas admission changes

Member cost share for inpatient admissions to facilities overseas is waived when the Worldwide Assistance Center (provided by AXA Assistance) has arranged direct billing or acceptance of a guarantee of benefits with the facility. Previously, members were responsible for a copayment or coinsurance for these admissions.

Following are changes to our Standard Option only:

We now limit preventive dental care benefits for the topical application of fluoride or fluoride varnish to up to two services per person per calendar year. Previously, there was no benefit limit for these services.

We revised our dental benefits to provide a fee schedule for each extraoral diagnostic image. Previously, dental benefits included references to both “extraoral - first image” and “extraoral - each additional image.”

Following are changes to our Basic Option only:

We’ve reduced the member responsibility for sleep studies performed in the home and billed by preferred professional providers.

The enrollment codes for 2017 remain the same: