OPM has placed continued emphasis on access to and availability of behavioral health provider networks. Image: DOERS/Shutterstock.com
By: FEDweek StaffFollowing is the section of an OPM guide to the now-ongoing open season, running through December 9, addressing areas of expanded coverage for 2025 in the FEHB program and the new PSHB program.
For the 2025 Plan Year, OPM is pleased to continue to promote benefit offerings in the following areas across the FEHB and PSHB Programs: Contraception, Fertility, Maternal Health, Mental Health/Substance Use Disorders, Prevention and Treatment of Obesity benefits, and Pharmacy Coverage. Contraception All Carriers – FEHB and PSHB – cover, without cost sharing, at least one form of contraception from each category listed in Women’s Preventive Services Guidelines supported by the Health Resources & Services Administration (HRSA) inclusive of sterilization surgery for women and have a process where members and providers can request an expedited exceptions review for medically necessary medical or surgical contraception options.
Fertility
In Plan Year 2025:
• All 64 FEHB plans and 30 PSHB plans provide coverage of artificial insemination (intrauterine insemination, intracervical insemination, and intravaginal insemination).
• All 64 FEHB plans and 30 PSHB plans provide coverage for up to 3 cycles of in vitro fertilization (IVF) drugs.
• For Plan Year 2025, 25 FEHB plans, offering a total of 45 plan options, will cover IVF, inclusive of IVF medical services, procedures and IVF drugs. Seven (7) of the plans are new for 2025. More than 1.5 million members (37%) have access to IVF services, procedures, and drugs. The other 63% have the opportunity to change to a plan that covers IVF procedures, if they desire.
• 11 PSHB plans offering a total of 19 plan options will cover IVF, inclusive of IVF medical services, procedures, and IVF drugs.
• With more than one nationwide plan offering coverage, all (100%) FEHB and PSHB eligible enrollees will have the opportunity to choose a plan that covers these services and procedures during the upcoming Open Season.
• Please note that coverage for IVF medical services and procedures varies between plans and interested members are encouraged to carefully review plan brochures for details. Interested members are also able to access this information through OPM.gov at 2025 FEHB IVF Information and 2025 PSHB IVF Information.
Maternal Health
Maternal health is an ongoing focus and for Plan Year 2025, with several Carriers include specialized programs for persons with high-risk pregnancies. Carriers continue to provide strategies and programs that help to avert costly interventions and safer births. Some Carriers continue to include in-network hospitals that have received the Healthy People 2030 goal of a cesarean birth rate of 23.6% or lower, hospitals who have been recognized by Leapfrog for maternity care safety, and hospitals that have received the “Birthing-Friendly” or the Baby-Friendly Hospital Initiative designation.
Key highlights include: FEHB plans provide coverage for the following maternal health benefits:
• All 64 FEHB plans cover mental health treatment for postpartum depression
• All 64 FEHB plans provide prenatal and post-partum care mental health screening and treatment
• 63 plans cover certified nurse midwives
• 41 plans cover delivery at birth centers
• 63 plans provide coverage for lactation specialists o Several plans offer an additional level of lactation support by providing access to board certified lactation consultants as recommended by the US Surgeon General o At least 11 plans have this level of provider in their network
• 46 plans cover medically necessary nurse home visits; and
• 30 plans provide access to doula benefits.
PSHB plans provide coverage for the following maternal health benefits:
• All 30 PSHB plans cover mental health treatment for postpartum depression
• All 30 PSHB plans provide prenatal and post-partum care mental health screening and treatment
• 29 plans cover certified nurse midwives
• 18 plans cover delivery at birth centers
• All 30 plans cover lactation specialists o Several plans offer an additional level of lactation support by providing access to board certified lactation consultants as recommended by the US Surgeon General o At least 7 plans have this level of provider in their network
• 28 plans cover medically necessary nurse home visits; and
• 9 plans provide access to doula benefits.
Mental health and substance use disorders
OPM has placed continued emphasis on access to and availability of behavioral health provider networks in view of recent public health crises including the COVID-19 pandemic, youth mental health, and the opioid epidemic. OPM continues to work with FEHB Carriers on the establishment of program-wide network adequacy strategies that improve access to high quality behavioral health services.
• All 64 FEHB Plans cover at least one opioid overdose rescue agent without cost sharing and educate members and providers on opioid misuse through their websites. In addition, several Carriers such as Blue Cross Blue Shield, UHC, CareFirst, Aetna, and Kaiser plan options, indicate medical, pharmacy, behavioral and mental health care is integrated to treat opioid use disorder and aid member recovery.
• All 30 PSHB Plans will offer the same benefits as their FEHB plans.
Prevention and treatment of obesity
OPM continues to emphasize that Carriers offer an obesity management benefit that includes access to nutritional and physical activity supports and intensive behavioral therapy, OPM has required that FEHB Carriers provide adequate coverage of metabolic surgeries and FDA approved anti-obesity medications to meet patient needs and requires that these medications be accompanied by nutrition and behavioral supports. As of 2023, Carriers must cover at least one anti-obesity drug from the GLP-1 class for weight loss and cover at least 2 additional oral anti-obesity drug options. As new anti-obesity drugs are approved by the FDA, OPM expects Carriers to evaluate and update their coverage of anti-obesity drugs.
For the 2025 plan year:
• All 64 FEHB Plans provide an obesity benefit that includes access to nutritional counseling, behavioral interventions, coverage for anti-obesity medications when clinically indicated and bariatric surgery when clinically indicated
• All 30 PHSB Plans offer the same obesity benefit as their FEHB plans
• All Carriers provide an obesity benefit for children, adolescents and adults.
Pharmacy coverage
All FEHB and PSHB Carriers provide online formularies and drug price comparison tools on their websites for enrollees. These tools provide current and prospective enrollees convenient access to accurate prescription drug information, including but not limited to, formularies, tiering, member cost-share, and utilization management requirements for covered prescription drugs during Open Season and throughout the plan year.
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