Prior Approval Lists and Forms

For Washington and Alaska

Prior approval lists by plan

Standard and Basic Options prior approval list
Federal Employees Health Benefits (FEHB) (effective January 1, 2024)
FEP Blue Standard: 104, 105, 106
FEP Blue Basic: 111, 112, 113
(Noted on the member's ID card.)
 
Postal Service Health Benefits (PSHB) (effective January 1, 2025)
FEP Blue Standard:  33D, 33E, 33F
FEP Blue Basic: 33A, 33B, 33C
(Noted on the member's ID card.)

Blue Focus prior approval list
Federal Employees Health Benefits (FEHB) (effective January 1, 2024)
FEP Blue Focus: 131, 132, 133
(Noted on the member's ID card.)

Postal Service Health Benefits (PSHB) (effective January 1, 2025)
FEP Blue Focus: 35A, 35B, 35C
(Noted on the member's ID card.)

Prior approval/pre-service request forms for services provided in Alaska or Washington only

Alaska prior approval form
Washington prior approval form
Alaska precertification/concurrent review request form
Washington precertification/concurrent review request form

Applied behavior analysis (ABA) prior approval forms

Alaska ABA prior approval form
(Eastern) Washington ABA prior approval form

Durable medical equipment (DME) prior approval forms

Alaska DME prior approval form
Washington DME prior approval form

For services outside Alaska or Washington

Please contact the local Blue plan where the service is provided.

For more information, call 877-342-5258.