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Blue Choice PPOSM Provider Manual Federal Employee Program (FEP )Important note:In thisSectionUpdated 08-12-2021Throughout this provider manual there will be instances when there are references unique to BlueChoice PPO, Blue High Performance Network, Blue Edge, EPO and the Federal EmployeeProgram These specific requirements will be noted with the plan/network name. If a Plan/networkname is not specifically listed or "Plan" is referenced, the information will apply to all PPO products.The following topics are covered in this section.TopicPageFederal Employee Program (FEP) OverviewH—2No PCP or ReferralsH—2Enrollment CodesH—2Option DefinedH—2Federal Employee Program Group NumberH—2FEP Blue Focus OptionH—3FEP Blue Focus Option Sample ID CardH—3Basic OptionH—4Basic Option Sample ID CardH—4Standard OptionH—5Standard Option Sample ID CardH—5Federal Employee Customer ServiceH—6Telephone Number and HoursH—6Online AccessH—6Mailing AddressH—6Prior Approval/Authorization RequirementsH—7Inpatient/Outpatient Prior Approval/AuthorizationH—7How Do I Obtain a Prior Approval/AuthorizationH—9Behavioral Health Prior Approval/AuthorizationH—9FEP Claims FilingH — 10FEP Claims InquiriesH — 10FEP Pharmacy ProgramsH — 10FEP Disease Management ProgramsH — 10FEP Blue Health ConnectionH — 11Page H — 1A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Choice PPO Provider Manual Federal Employee Program (FEP)FederalEmployeePlan (FEP)OverviewBlue Cross and Blue Shield Service Benefit Plan is the officialname of coverage offered to federal employees and annuitantsby participating Blue Cross and Blue Shield Plans. This plan iscommonly referred to as the Federal Employee Program or FEP.FEP benefits may be redefined annually as negotiated by theBlue Cross Blue Shield Association and the Office of PersonnelManagement in Washington, D.C.FEP utilizes the Blue Choice PPO network.No PCP orReferralsSubscribers of the Service Benefit Plan do not choose a primarycare physician, and referrals are not required, however,Standard Option subscribers must seek care from aparticipating Blue Choice PPO health care provider in order toreceive the highest level of benefits, and Basic Optionsubscribers only have in network level benefits with fewexceptions.EnrollmentCodesEligible Federal employees, tribal employees and annuitantsmay enroll in the Federal Employees Health Benefits Program.Refer to https://www.opm.gov/ for additional information.The federal ID card is quite different from Blue Choice PPOID card. The following is a key to the Service Benefit Planenrollment codes that appear on the federal ID card.EnrollmentCode104105106111112Benefits ForBenefit OptionSelf OnlySelf and FamilySelf Plus OneSelf OnlySelf and 1132Self and FamilyFEP Blue FocusFEP Blue Focus133Self Plus OneFEP Blue FocusSelf Plus OneSelf OnlyOptionDefinedThree health plans options are offered to FEP members: FEPBlue Focus, Basic Option, and Standard Option.FEP GroupNumberFederal Employee Program group number is 0FEPTX. This groupnumber needs to be entered in Block 11 on the CMS 1500 claimform or in Block 62 on the UB 04 claim form.Updated 08-12-2021Page H — 2

Blue Choice PPO Provider Manual Federal Employee Program (FEP)FEP BlueFocusOptionFEP Blue Focus is a PPO with a nationwide network includinghospitals, physicians, and numerous ancillary/specialtyproviders. FEP Blue Focus: Is an in-network-only benefit program that requiresmembers to use PPO providers in order to receivebenefits. Offers unique design with services categorized by core,non-core, and wrap benefits. Core services include full coverage for preventive care,the first 10 office visits per year with a 10.00 copaymentfor both PCP and specialists. A 500/individual and 1000/family deductible applies to non-core benefits.FEP Blue FocusSampleID CardFEP Blue Focus ID Card (front & back):Updated 08-12-2021Page H — 3

Blue Choice PPO Provider Manual Federal Employee Program (FEP)Basis OptionBasicOptionSampleID CardUpdated 08-12-2021Basic Option Plan: Is a PPO with a nationwide network including hospitals,physicians and numerous ancillary and specialtyproviders. Is an in-network-only benefit program that requiresmembers to use PPO providers in order to receivebenefits. Has no calendar year deductible. Most services are reimbursed in full of the plan allowanceafter an applicable member copayment. Office visit copayment is 30 for a Preferred Primary CarePhysician and 40 for a Preferred Specialist.Basic Option ID Card (front & back):Page H — 4

Blue Choice PPO Provider Manual Federal Employee Program (FEP)StandardOptionStandard Option Plan: Is a PPO with a nationwide network including hospitals,physicians, and numerous ancillary and specialtyproviders. Members must use PPO providers to receive preferred(network) benefits. Members may also use non-PPO providers, participating,or non-participating. When a non-PPO provider is used,the member will receive a lower benefit level. Office visit copayment is 25 for a Preferred Primary CarePhysician and a 35 copayment for a Preferred Specialist.Other non-preventive services are first subject to a 350/individual or 700/family calendar year deductibleStandardOption IDCardStandard Option ID Card (front & back):Updated 08-12-2021Page H — 5

Blue Choice PPO Provider Manual Federal Employee Program (FEP)FederalCustomerServiceBCBSTX provides a dedicated Federal Customer Servicestaff. The Customer Service representatives have access tofederal subscriber information to give prompt inquiryresponse to: Benefits and subscriber eligibilityClaimsCurrent Preferred Provider network informationFormal and informal complaint proceduresThe automated phone system also provides information for: TelephoneNumberand HoursBenefitsEligibilityClaims PaymentYou may reach the BCBSTX Federal Customer Service bycalling:1-800-442-4607Hours: 8 a.m. - 5 p.m. Central Standard Time (CST), Mon- FriOnlineAccessUtilize Availity for online access to benefits and eligibilityand claims status.MailingAddressFederal Customer Service may also be contacted inwriting at the following address:FEP Customer ServiceP.O. Box 660044Dallas, TX 75266-0044Updated 08-12-2021Page H — 6

Blue Choice PPO Provider Manual Federal Employee Program (FEP)PriorApproval/AuthorizationRequirementFor information on FEP Medical Policies and UtilizationManagement Guidelines, please visit www.fepblue.org andselect the Policies & Guidelines link at the bottom of thepage. For Plan Brochures, select “Tools and Resources” at thetop of the page, then “Brochures & Resources” and val/AuthorizationRequirementsAll inpatient hospital admissions require prior approval/priorauthorization.*All requirements listed below are annually updated and arelocated in our FEP Service Benefit Plan Brochure which can befound at www.fepblue.org . Please check the brochure forverification of any updates that may not be listed below.You must obtain prior approval for the below services underboth Standard and Basic Option. Prior authorization is alsorequired if the service or procedure requires an inpatienthospital admission. Gene therapy and cellular immunotherapy, for exampleCAR-T and T-Cell receptor therapy Non-Emergent Air Ambulance Transport Outpatient sleep studies any location other than your home Applied behavior analysis (ABA) Gender reassignment surgery BRCA testing and testing for large genomic rearrangementsin the BRCA1 and BRCA2 genes Surgery for morbid obesity Surgical correction of congenital anomalies Surgery needed to correct accidental injuries to jaws,cheeks, lips, tongue, roof and floor of mouth Intensity-modulated radiation therapy (IMRT) allowedexceptions are listed in our FEP Service Benefit PlanBrochure Hospice care Transplants – see our FEP Service Benefit Plan Brochure forfacility and specific requirement- Organ/tissue transplants -Prior approval is required forboth the procedure and the facility.- Blood or Marrow Stem Cell transplants- Clinical trials for certain blood or marrow stem celltransplants- Transplant travel Prescription drugs and supplies -See Pharmacy section andour FEP Service Benefit Plan BrochureUpdated 08-12-2021Page H — 7

Blue Choice PPO Provider Manual Federal Employee Program onRequirements,cont.FEP Blue Focus - You must obtain prior approval for thefollowing services. Failure to obtain prior approval will result in a 100 penalty. Prior authorization is also required if the serviceor procedure requires an inpatient hospital admission. Gene Therapy and Cellular Immunotherapy, including Car-Tand T-cell receptor therapy Non – Emergent Air Ambulance Transport Applied behavior analysis (ABA) Genetic testing including the following:- BRCA screening or diagnostic testing- Large genomic rearrangements of the BRCA1 and BRCA2genes screening or diagnostic testing- Genetic testing for the diagnosis and/or management ofan existing medical condition Surgery to treat morbid obesity Breast reduction or augmentation not related to treatment ofcancer Gender reassignment surgery Surgical correction of congenital anomalies Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips,tongue, roof and floor of the mouth, and related procedures Orthognathic surgery procedures, bone grafts, osteotomiesand surgical management of the temporomandibular joint(TMJ) Orthopedic procedures: hip, knee, ankle, spine, shoulder andall orthopedic procedures using computer-assistedmusculoskeletal surgical navigation Reconstructive surgery for conditions other than breast cancer Rhinoplasty Septoplasty Varicose vein treatment Intensity-modulated radiation therapy (IMRT) allowedexceptions are listed in our FEP Service Benefit Plan Brochure Hospice care Cardiac rehabilitation Cochlear implants Residential Treatment Center care for any condition Prosthetic devices (external) Pulmonary rehabilitation Radiology, high technology including MRI, CT and PET scans Specialty durable medical equipment (DME)(List continued on next page)Updated 08-12-2021Page H — 8

Blue Choice PPO Provider Manual Federal Employee Program onRequirements,cont. Transplants – see our FEP Service Benefit Plan Brochurefor facility and specific requirements- Organ/tissue transplants -Prior approval is requiredfor both the procedure and the facility.- Blood or marrow stem cell transplants- Clinical trials for certain blood or marrow stem celltransplants- Transplant travel Prescription drugs and supplies -See Pharmacy sectionand our FEP Service Benefit Plan BrochureHow Do I ObtainPrior Approval/Authorization?To obtain inpatient prior approval/authorization (excludingbehavioral health) or outpatient prior approval/authorization,call:Medical Management at1-800-441-9188BehavioralHealth PriorApproval/AuthorizationInpatient hospital admissions require prior approval/authorization under the Federal Employee Program.To prior approve/authorize behavioral health inpatientadmissions, call:1-800-528-7264Outpatient behavioral health services do not require priorapproval/authorization.If you or your FEP patient have questions or needinformation about behavioral health professionals, facilitiesor procedures, call 1-800-528-7264.Updated 08-12-2021Page H — 9