Prior Approval Database

Search by CPT® or HCPCS code, or the name of the item to find services, equipment and supplies that need prior approval. If the service and applicable CPT® or HCPCS code appears below, we require prior approval even if the plan is secondary to another carrier, including Medicare.

Unless otherwise indicated, the following health plans do not require prior approval for the services within this database:

• The State of Vermont Total Choice Plan (prefix FVT) 
• Vermont Blue65 and Vermont Medigap Blue supplement plans (prefix ZIB)

This database applies to the following health plans:

• Blue Cross Vermont (Note: Blue Cross VT includes Access Blue New England (ABNE), New England Health Plan (NEHP), and The Vermont Health Plan)
• International Brotherhood of Electrical Workers (IBEW Local 300)
• The State of Vermont (Administrative Services Only)

Act 111 – Blueprint Primary Care Provider waiver of prior authorization: Effective for dates of service January 1, 2025 or after, prior authorization is waived for eligible primary care providers who order a qualifying service for a qualifying member. If you are not familiar with Act 111 and the waiver, please see Section 12 of our online Provider Handbook.
 

Prescription drugs: Please note that prescription drugs requiring prior approval are not listed in this database. Please refer the Vermont Blue Rx Center for drugs requiring prior approval. For State of Vermont plans, contact the pharmacy benefits manager for information.

Prior approval requirements and member benefits vary according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates, and member contract language takes precedence over medical policies or the prior approval database when there is a conflict. Please verify member benefits prior to rendering services.