Provider Policies

We’re committed to supporting you in providing quality care and services to our members. Here you will find information on our medical policies, quality improvement program standards, and billing guidelines. The Provider Resource Center provides access to many of our forms, policies, and updates.

You can access our out-of-area medical policy router via the Out-of-Area Medical Policy Access accordion below.

Provider Policies

These documents are provided for informational purposes only and are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied.  Benefits are determined by the subscriber certificate that is in effect at the time services are rendered. Medical practices and knowledge are constantly changing, and we reserve the right to review and revise medical policies periodically and without notice.

When available, we may utilize Blue Cross and Blue Shield of Vermont approved medical policies or those specific to plans as outlined below.  When an appropriate policy does not exist we may utilize the medical policies of the national Blue Cross & Blue Shield Association as guidance to determine medical necessity. These policies are available on request.

BlueCard Members: To look up out-of-area member's medical policies, please use the Out-of-Area Network Policy option at the bottom of this page.

Updated: 11.07.2024

Archived medical policies are inactive and no longer updated. Archived policies will remain available for a period of one year. Policies may be archived due to the technology being obsolete or discarded, the technology becoming standard of care and details about its use are well known, and/or Blue Cross and Blue Shield of Vermont is no longer implementing the policy.

The information in the archived policies is current through the last review date before the policy was archived. These policies may be useful for providing background information or for understanding benefit determinations made when the policy was active. However, because archived policies are not updated, providers should not rely on them as a source of information with respect to current requests for coverage.

Blue Cross VT Pharmacy Base Policies

  • Down-tiers: Medications may move to a lower tier throughout the year. Utilization management strategies such as Step Therapy, Quantity Limits or Prior Authorization may apply.
  • Up-tiers: Medications typically move to a higher tier on Jan. 1 and July 1 to help reduce member disruption. Brand medications may move to a higher tier at any time when a generic equivalent becomes available. Utilization management strategies such as Step Therapy, Quantity Limits or Prior Authorization may apply.
  • New Generic Launches: New generic medication launches occur throughout the year. Generic medications will be placed in Tier 1 on the Select and Premium (NPF) Formularies. Brand medications may move to a higher tier at any time when a generic equivalent becomes available.
  • New Drugs to Market: May include new brand launches and Authorized Brand Alternatives. These products are excluded from coverage for up to 6 months, however a formulary exception override process is available via Prior Authorization. Final coverage status is determined after medications are thoroughly reviewed by the Optum Rx National Pharmacy & Therapeutics Committee. 
  • Specialty Medication Updates: These occur on Jan. 1 and July 1 and include existing medications being added to or removed from the Specialty Pharmacy Program.
  • Step Therapy: Step Therapy directs members to try a lower-cost alternative (Step 1) before a higher-cost medication (Step 2) may be eligible for coverage. Step Therapy may be removed at any time but will only be added on Jan. 1 and July 1 to help reduce member disruption.
  • Quantity Limits: Quantity limits establish the maximum quantity of a drug that is covered within a specified timeframe. Quantity Limits may be removed at any time but will only be added on Jan. 1 and July 1 to help reduce member disruption. Existing utilization management such as Prior Authorizations and Step Therapy may still apply.

View Blue Cross and Blue Shield of Vermont’s practice standards and how we monitor those as part of our quality program.

By accessing these policies, I acknowledge the following:

Blue Cross and Blue Shield of Vermont’s payment policies:

  • Serve as a reference to assist providers and facilities in submitting accurate claims.
  • Outline the basis for reimbursement for covered services.
  • Apply to services rendered by participating providers.
  • Are subject to changes in coding rules and guidelines, such as those established by CPT and HCPCS; there may be instances where coding changes are applied before the policies are amended.
  • May be revised from time to time based on state or federal requirements or changes to provider contracts.

Blue Cross VT payment policies do NOT:

  • Provide billing or coding advice.
  • Guarantee or determine benefits.
  • Control in the event of a conflict with member contracts, provider contracts, medical policies, or claim edits.
  • Dictate how other Blue Plans set allowances for care rendered by non-participating providers.
  • Constitute medical advice.

Permanent Payment Policy Name

In effect until December 31, 2024

The clinical practice guidelines serve as resources that aim to standardize healthcare practices by adopting evidence based guidelines which can help positively impact outcomes. The guidelines can assist practitioners, as well as members, in making informative decisions about appropriate health care for specific clinical situations.

Blue Cross VT’s quality program has adopted guidelines for clinical practice that includes, but is not limited to, the list of resources below. The listed guidelines are one of the many resources utilized by Blue Cross VT to reach decisions on matters of medical policy, benefit coverage, and utilization management.

Center for Disease Control and Prevention (CDC)

U.S. Preventive Services Task Force (USPST)

American Psychiatric Association (APA)

National Heart, Lung and Blood Institute (NHLBI)

American College of Cardiology (ACC)

American Academy of Child and Adolescent Psychology

Global Initiative for Chronic Obstructive Lung Disease

American Diabetes Association

Blue Cross and Blue Shield of Vermont Preventive Care Guide

If you would like to receive any or all of these guidelines by mail, please call (800) 924-3494 or email customerservice@bcbsvt.com.

Updated: 09/19/2024

To view the out-of-area Blue Plan's medical policies or general pre-certification/pre-authorization information, please select the type of information requested, enter the first three letters of the member's identification number on their Blue Cross Blue Shield ID card, and click "GO".

Type of information being requested

If you experience difficulties or need additional information, please contact (800) 676-BLUE or provider services at (800) 924-3494.

Date modified : 09/08/2010

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Provider Handbook

Access our Provider Handbook for a comprehensive reference of resources and requirements for Blue Cross providers.

Provider Handbook
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Preventive Care Benefits for Members

Through our plans, members have certain preventive care benefits - learn more about our member coverage details.

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