Coverage

Preventive care refers to health care services meant to help you avoid serious medical problems through routine care and screening. Some preventive care services help identify a health issue before it becomes very serious—like your cholesterol test, while other preventive care services help prevent a health issue before it happens—like your annual flu shot.

View our preventive care flyer

Are all preventive care services free?

No. Many services that are considered preventive in terms of your personal health do not meet the guidelines for zero-cost preventive care. There are two factors that determine whether a preventive care service is available to you at no cost:

1. The recommended guidelines for preventive care services are appropriate for your age. The specific preventive services that are available to you at zero cost will vary throughout your lifetime based on your age. This guide outlines coverage for services such as vaccines, contraceptives, and screenings.
2. The medical information provided on your claim. 

Generally speaking, a service usually does not qualify as zero-cost preventive care if a medical problem is known, suspected, or found during the course of care. This means that you may have to pay some of the cost of an otherwise qualified service (such as a copay, coinsurance, or deductible) based on your personal medical situation.

Here are some quick tips to help you and your provider determine when services may not be part of the preventive benefit:

• Medical office visits or physical exams to establish a member with a new provider or to diagnose, treat, or monitor a condition or risk factor.
• Laboratory services that are not specifically defined as preventive care within the federal recommendations for your age.
• Services that are diagnostic or therapeutic in nature.
• Services intended to monitor existing conditions for ongoing maintenance or surveillance of potential complications.

If you receive coverage under a retiree benefits plan, you may not have zero-cost preventive benefits available to you. Check your benefits in the Member Resource Center or contact customer service at (800) 247-2583 for more information.

Read more about getting lab tests

I received a bill for care that I thought would be free. What happens now?

When it comes to zero-cost care, it is very important to review your benefits coverage in advance. Make sure you understand any requirements or limitations for zero-cost care before your appointment. Once you have received care from a facility or provider, you will be responsible for any copays, coinsurance, or deductibles that apply.

What if I still don’t understand whether a care or service should be free for me?

If you have any questions about your plan coverage, benefits limitations, or the specific preventive care and screening services that are available to you or your family members, contact customer service before your scheduled care appointment. We’re here to help you!

Depending on your health plan, you have access to certain mental health and substance use disorder treatment services for the same co-payment as your primary care physician (PCP) visit. To receive these services at the same cost as your PCP visit, the following apply:

• You must use a Blue Cross Vermont network provider.
• The provider must designate the service you received as one of the covered services listed below. We have included the list of services and codes below that we cover at the same co-payment as your PCP visit.
  • If your service is not on the list below, you will pay the specialist co-payment amount.

Benefit Update for Opioid Use Disorder Support Services

Starting October 1, we will now cover opioid use disorder support services offered by qualifying providers and delivered in their offices. While this expands covered services, some members with high-deductible health plans may incur upfront costs. To understand potential impacts for your out-of-pocket costs, please verify your plan benefits or call the Customer Service number on the back of your health insurance ID card.

While the COVID-19 public health emergency has ended, new variants of the virus continue to emerge and new vaccines are being released. Below we outline your coverage related to COVID-19 vaccines, test, and more.

COVID-19 Vaccines

COVID vaccinations and booster shots will continue to be covered at no cost to members.

The 2023-2024 vaccines that protect against the more current strains of the COVID-19 virus will be available to Vermonters in the coming weeks. Check with your primary care provider's office or local pharmacies on availability. You can also visit vaccines.gov to find locations near you.

COVID-19 Tests

At-home COVID-19 antigen tests (test kits) are no longer be covered. Provider-based COVID-19 tests will be covered with a cost-share.

Note: If you have coverage through your employer and do not have our Vermont Blue Rx pharmacy coverage, please contact your employer for more information about your coverage for COVID-19 tests.

Before you throw out expired COVID-19 antigen tests, check to see if the expiration date has been extended.

Medications to Treat COVID-19

Oral medications used to treat COVID-19, including Paxlovid and Lagevrio (Molnupiravir), are covered with a Tier 3 cost-share. Injectable medications used to treat COVID-19, administered by your doctor and that are FDA-authorized or FDA-approved, will be covered with a cost-share.

If you do not have pharmacy coverage through Vermont Blue Rx, please contact your employer for more information about your coverage for COVID-19 medications.

Additional Benefits & Coverage

• In-patient and out-patient COVID-19 treatment will have a cost-share.
• Telemedicine visits with Amwell for COVID-19  will require a member cost-share.

Blue Cross Blue Shield Global Core gives Blue Cross and Blue Shield of Vermont members access to their health care benefits wherever they go - across the country and around the world. Enrollment in the program is automatic and available to all Blue members.

• Domestic Travel
  When traveling outside of Vermont you may need access to medical services. The Blue Cross and Blue Shield Association's National Doctor and Hospital Finder may help you find providers within the United States and its territories.
• International Travel
  Traveling outside the United States requires planning, but you can be certain that your health care coverage with Blue Cross and Blue Shield of Vermont travels with you through our Blue Cross Blue Shield Global Core program. Visit the Blue Cross Blue Shield Global Core website to help you find international providers, file international claims and more.

Planning Your Trip

Before you travel, contact your Blue Cross and Blue Shield (BCBS) company for coverage details. Coverage outside the United States may be different. Be sure to always carry your current member ID card with you when traveling. 

• If you need inpatient care, call the Blue Cross Blue Shield Global Core Service Center at (800) 810-2583 to arrange direct billing. In most cases, you should not need to pay upfront for inpatient care except for the out-of-pocket expenses (noncovered services, deductible, copayment and coinsurance) you normally pay. The hospital should submit the claim on your behalf. Please note that you may still need prior approval for services. For assistance, contact our customer service team using the number on the back of your ID card.
• For outpatient and doctor care or inpatient care not arranged through the Service Center, you may need to pay upfront. Submit a Blue Cross Blue Shield Global Core International claim form  . Please note, it could take up to 30 days for a claim to process and up to 45 days for reimbursement.

Certain services, supplies, and prescription drugs require advance (prior) approval before benefits are provided. This ensures the services are diagnostically appropriate, medically necessary, and cost effective.

Blue Cross and Blue Shield of Vermont network providers get prior approval for you. If the Vermont network provider fails to get prior approval for services that require it, the provider may not bill you. Work directly with your provider to request the proper prior approval. We must respond to all prior approval requests within two business days, and requests should be submitted before the member's appointment. You and your provider will be notified once the BlueCross team has reviewed the information.

• List of services, equipment and supplies requiring prior approval (PDF)
• Prior Approval Form
• Prescription drugs requiring prior approval

If you use an out-of-network provider or an out-of-state provider, it's your responsibility to get prior approval. Failure to get prior approval could lead to denial of benefits. If you can show that the services you received were medically necessary, we will provide benefits.

To check the status of your prior approval, log in to the Member Resource Center.