Provider News & Updates
Below you will find the latest on important information that may impact your practice, as well as copies of letters and notices we have released.
News and Updates
May 13, 2025
2026 Coverage Changes for GLP-1 Drugs FDA-Approved for Weight Management
Beginning January 1, 2026, Blue Cross Vermont will no longer cover prescription GLP-1 drugs that are FDA-approved for weight management, such as Wegovy®, Zepbound®, and Saxenda®, for our Qualified Health Plan (QHP) and Blue Edge Business members. We will continue to cover GLP-1 drugs prescribed as a treatment for members with Type 2 diabetes.
Members who are affected by this coverage change will be notified by mail the week of May 12. If they choose to continue using GLP-1 medications for weight management on or after January 1, 2026, they will be responsible for the full cost. For additional information on this upcoming change in drug coverage, please contact our Customer Service team at (800) 247-2583 or view the FAQ document we developed for members.
May 1, 2025
Medical and Payment Policy Updates
Check out the payment and medical policy updates that go into effect July 1, 2025.
May 1, 2025
Change in Enrollment Process of Locum Tenens
Beginning July 1, 2025, all locum tenens must complete a provisional credentialing process. Locum tenens will not be eligible to render care to Blue Cross and Blue Shield members until the provisional credentialing process is complete.
View our notice for more information on the upcoming changes.
May 1, 2025
July 1, 2025 Pharmacy Updates
- In April, providers received patient-specific communications about any negative formulary changes effective July 1, 2025.
- Stelara (ustekinumab) will be excluded on the NPF and BCBSVT formulary.
- Currently, the interchangeable biosimilar, Wezlana is also on the formulary. It does not require prior authorization and will be the preferred option starting July 1, 2025. This medication is a biologic used for inflammatory conditions such as plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.
- View the full list of drug changes for July 1, 2025
May 1, 2025
Reminder: Unlisted Procedure, Service, or Supply Codes
Providers should always bill a defined procedure, service or supply code when one is available. If a defined code is not available, services can be billed using the unlisted code. For details on how to submit and request a review of unlisted codes, read our updated notice.
May 1, 2025
Preventive Care Guide Updates
The preventive care guide has been updated with additional codes. The changes go into effect July 1, 2025. Review our notice for more details.
May 1, 2025
Real-Time, Free Psychiatric Consultations for Child and Adolescent Primary Care Providers
The Vermont Consultation and Psychiatry Access Program (VTCPAP) offers real-time consultations for primary care providers treating children and adolescents. A team of licensed clinical social workers and board-certified child and adolescent psychiatrists are available to answer questions about assessments, screenings, treatment planning, or medication management. VTCPAP can help address your patients’ needs quickly and comprehensively, as well as aid in finding referrals to mental healthcare services. Visit their web site at www.vtcpap.com for more information and to access their services.
May 1, 2025
Updated BlueCard Appeal Form
We have updated the BlueCard Appeal form and posted it to the provider website. If you have printed a supply of this form, or have saved a version to your computer, please download and use the updated form.
Appeals for all BlueCard claims are handled through Blue Cross VT. We coordinate the appeal process with the member’s Blue Plan. Completed forms can be emailed to bluecard@bcbsvt.com or faxed to (802) 225-7698. You will be notified of the outcome of your appeal within 30 days of receipt.
Reminders:
- A BlueCard appeal form should only be used when there is a confirmed denial of benefits.
- Timely filing denials are not appealable and cannot be submitted on an appeal form.
- If you would like a timely filing reviewed, attach documentation supporting the filing to a payment inquiry form and send to bluecard@bcbsvt.com.
- Some Blue Plans may require members to sign an additional form specific to their Plan before they start an appeal process.
May 1, 2025
Provider Quality Policy Updates
The following provider quality policies have been updated, with changes effective July 1, 2025: practitioner credentialing, facility credentialing, and quality of care risk investigations.
May 1, 2025
CareCentrix Infusion Site of Care Program Begins in May
Blue Cross VT has partnered with CareCentrix to offer eligible members an alternate site for certain infusion therapies. This voluntary program applies to a specific group of drugs that have been approved by the health plan. Members will only transition to the home or infusion center if both the member and prescriber agree to the change.
Who is CareCentrix?
CareCentrix empowers health at home through whole-person care coordination and benefit management – helping payors and providers close gaps in care while helping lower costs and improving member outcomes. CareCentrix has 20+ years of experience coordinating infusion services for 500+ drugs and managing care transitions to an alternate site of care, including home and infusion centers. For more information about CareCentrix, visit https://www.carecentrix.com.
Questions about the program?
- If a member has questions about the Infusion Site of Care program, please direct them to call CareCentrix at (833) 592-1089.
- For providers with general questions about the program, contact Provider Customer Service at (800) 924-3494.
May 1, 2025
ClaimsXten-Select™ Upgrade
We have scheduled an update to ClaimsXten-Select™ for Tuesday, July 1, 2025. Review the notice to understand the upcoming changes.
May 1, 2025
Provider Handbook Changes
The provider handbook has been updated to reflect changes related to BlueCard appeals, provider credentialing, and claims guidelines and appeals.
April 1, 2025
eNewsletter CORRECTION
Our April 1, 2025, eNewsletter for Telemedicine Updates contained an error. CPT®code 99211 will remain eligible for telemedicine services after June 1, 2024.
March 28, 2025
Telemedicine Updates
Reminder: We cover telemedicine services for Blue Cross VT members, but there are new Office-based Evaluation and Management Services (E/M) codes that must be billed for telemedicine services. Review the changes to ensure you're using the proper codes.
As of June 1, 2025, codes 99202-99205 or 99211-99215, as well as modifiers other than -95 or -GQ, are no longer permitted for telemedicine billing. When billing for these services, refer to Attachment 1 of our Telemedicine Payment Policy (CPP_03) for the appropriate codes, or they will be denied as a provider liability. Members cannot be billed for services rendered by telemedicine that are not included in Attachment 1.
March 28, 2025
Provider Medical and Payment Policy Updates
Check out the payment and medical policy updates that go into effect June 1, 2025.
March 28, 2025
Preventive Care Guide Updates
The preventive care guide, effective June 1, 2025, includes updates for added, removed and corrected codes. Be sure to review our notice for more details.
March 28, 2025
Second Quarter CAA Directory Validation
- Second quarter Consolidated Appropriations Act (CAA) directory validations will be released the first week of April 2025.
- Validations MUST be completed by the end of April to ensure you will not be removed from our provider directory and risk possible contract termination.
- If you receive more than one email, please respond to all emails received. Some providers have multiple providers files and multiple verification needs to occur.
- If your practice was removed from the network due to non-response during the first quarter validation, this is your opportunity to be added back into the network directory.
- Details and instructions for the CAA directory validation are located on our Enrollment and Credentialing webpage, under the “CAA Directory Validation” section. If you have questions, please call (888) 449-0443, option 2, or email CAA@bcbsvt.com.
March 28, 2025
Pharmacy Updates
Downtiered Drugs
Drugs are evaluated regularly to be downtiered on the formulary, which may lower costs and increase options for your patients. The following drugs were downtiered in March 2025:
- Ebglyss (lebrikizumab-lbkz), for moderate to severe atopic dermatitis (eczema)
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand (Specialty) with prior authorization
- Opzelura (ruxolitinib), for moderate to severe atopic dermatitis (eczema) and nonsegmental vitiligo
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand with Step Therapy
- Zoryve (roflumilast) cream, for mild to moderate atopic dermatitis (eczema)
- BCBSVT and NPF Formulary: Tier 2 for 0.15% cream and Tier 3 for 0.3% cream Preferred Brand with Step Therapy
- Contour Plus Blood Glucose Test Strips, for diabetes or pre-diabetes
- BCBSVT and NPF Formulary: Tier 2 Preferred Brand with Quantity Limit
New Medication Alert
JournavxTM (suzetrigine) is a new non-opioid drug with a novel mechanism for treating moderate to severe acute pain in adults. It was approved by the FDA on January 30, 2025 and is a Tier 3 Non-Preferred Brand with a quantity limit on our formularies.
Covered Medications
March 28, 2025
Unlisted Codes – CPT® Procedure or Service Codes and Level II HCPCS Codes
CPT Category I and Category III codes cover most procedures and services performed and should be used for accurate reporting. There are instances when a specific code may not exist, and an unlisted procedure or service code may be reported. In these instances, the claim must be submitted on paper with the office and/or operative notes, and include a written description of the service that was supplied and being billed as an unlisted service.
March 28, 2025
Submitting Coding Denial Questions
If you have questions regarding a coding denial of a claim, review our new process for submitting questions. For more information about what qualifies as a coding denial, view our claims editing payment policy. Note: this new process does not apply to coding validation denials.
March 28, 2025
Community Fee Schedule Updates
We have completed the review of our community fee schedule for drugs administered or supplied in a provider’s office (MD Rx HCPCS), Home Infusion Therapy National Drug Codes (NDC), and Home Infusion Therapy Administrative Services. Updates go into effect on June 1, 2025. For a copy of the updated community fee schedule, contact our provider relations team at providerrelations@bcbsvt.com or (888) 449-0443, option 1. Please include your billing NPI number(s).
March 25, 2025
New Find-a-Doctor Tool Launched
We’re thrilled to announce the launch of our new find-a-doctor tool. This enhanced tool features advanced search options and integrates data from the Blue Card national doctor and hospital finder tool, making it easier for members to locate in-network providers nationwide, all in one place. The new find-a-doctor tool will be available through our website, bluecrossvt.org, and within the Member Resource Center (MRC).
March 13, 2025
New and Revised Codes for April 1, 2025 (Adaptive Maintenance)
We are in the process of completing our review of the CPT® and HCPCS additions and revisions for April 1, 2025. As a result, the off cycle Adaptive Maintenance eNewsletter providing the details of our implementation of the new and revised codes will be slightly delayed.
We will post an updated notice once the Adaptive Maintenance eNewsletter is released.
February 28, 2025
Medical Record Retrieval Project Kicks Off
Our annual Healthcare Effectiveness Data and Information Set (HEDIS®) data collection is currently under way! We appreciate your participation in this medical record review process, as it helps your peers and our members understand the quality of care your clinical team provides every day.
February 28, 2025
Provider Payment Policy Updates
View updates for provider payment policies, effective May 1, 2025.
February 28, 2025
Prior Authorization Changes
We continue to find opportunities to reduce the prior authorization requirements for our providers, while ensuring the highest standards of care for our members. In this ongoing effort, we have updated our list of services, equipment, and supplies to remove 13 service types. This will remove over 20% of our prior authorization service types. View the list to learn more about the changes.
February 28, 2025
Pharmacist-led Medication Therapy Management
We are happy to announce the launch of our new, pharmacist-led medication therapy management program. This program brings together our provider and member outreach to identify opportunities to improve our members care by analyzing claims and diagnosis data.
To help close gaps in care and prevent adverse outcomes by ensuring that our members are receiving medications that follow evidence-based best practice, providers may receive clinically appropriate recommendations. In these instances, providers will receive the information via fax, followed by a phone call.
February 28, 2025
Pharmacy Updates: New Generic Drugs and Biosimilars
When new generic drugs come out, they are usually preferred over brand medications due to potential cost savings. Two new drugs we are highlighting are:
- Liraglutide, a new generic drug of the brand diabetes medication Victoza. Liraglutide is a Tier 1 generic drug. Victoza is excluded on the NPF formulary and is a Tier 3 Non-Preferred Brand on the BCBSVT formulary.
- Wezlana, a new biosimilar to the biologic Stelara is on our NPF and BCBSVT formulary lists as a preferred specialty medication to treat many conditions, such as plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis. Stelara will continue to be included on our formulary. In the next year, more biosimilars to Stelara are anticipated to become available and will be considered for inclusion on our NPF and BCBSVT formulary lists.
Questions? Reach out to our Clinical Pharmacist, Amy Stoll, PharmD at stolla@bcbsvt.com or 802-371-3657 to discuss drug coverage or clinical questions.
February 28, 2025
Medical Record Activity Timeline
Check out our guide that outlines when we will be sending out HEDIS and risk-related medical record requests throughout the year.
February 28, 2025
ClaimsXten-Select™ Upgrade
We have scheduled an update to ClaimsXten-Select™ on Tuesday, April 1, 2025. Review the notice to understand the upcoming changes.
February 28, 2025
Provider Handbook Updates
Check out the latest changes to our Provider Handbook, sections 6.7 and 7. The updates provide clarifying details for these sections.E
February 28, 2025
Expansion of Eligible Hearing Aids
Effective May 1, 2025, we are expanding the existing list of eligible hearing aids for members who have the available benefits.
We now send a monthly provider e-newsletter, which is our primary source for all notices and updates. It replaces the individual notices you used to receive. The e-newsletter comes out at the beginning of every month. If there are other staff in your office that would like to be on our distribution list, please contact Provider Relations at providerrelations@bcbsvt.com.
Act 111 (H.766)
We are working hard to understand the impacts and business needs of Act 111, also known as H.766. We have a group of individuals across our organization implementing the necessary changes as it relates to prior authorization, claims processing, step therapy, and provider contracting.
As changes and updates become available, we will be keeping our providers informed through this webpage, as well as regular emails and enewsletters. Be sure to keep an eye on your email for regular updates as the work progresses.
Contact us at providerrelations@bcbsvt.com to be added to our email list.
Blueprint Primary Care Provider Prior Authorization Waiver
Beginning January 1, 2025, prior authorizations will be waived for eligible primary care providers who order a qualifying service (imaging, clinical laboratory, durable medical equipment, etc.) for a qualifying member.
Provider Requirements for Prior Authorization Waiver
- Must participate in Vermont Blueprint for Health;
- Must be enrolled, credentialed, and contracted with Blue Cross and Blue Shield of Vermont
While the provider does not need to be the Blue Cross VT member's selected primary care provider, the ordering provider must have engaged in clinical decision making for the ordered service.
Please note, only in-network services are eligible for a prior authorization waiver. Out-of-network services and prescription drugs require prior authorization.
Member Requirements for Prior Authorization Waiver
- The member is enrolled in a Qualified Health Plan, a large group fully insured plan, New England Health Plan/Access Blue New England, or a governmental plan (State of Vermont, University of Vermont, Vermont Education Health Initiative).
Learn how you can identify if a member qualifies for a prior authorization with our online instructions.
Claims Submission Requirements
If you are submitting a claim for services ordered by a Vermont Blueprint for Health primary care provider for a qualifying service and member, there are specific claim submission requirements that must be followed for the claim to bypass the prior authorization requirements automatically.
Working with our Pharmacy Benefit Manager (PBM), we are updating our policies and processes related to step therapy.
As we implement the requirements of Act 111, we will be sharing the ongoing updates to our policies and processes with you. Updates will be shared via email.
Provider Handbook
Access our Provider Handbook for a comprehensive reference of resources and requirements for Blue Cross providers.
Academic Detailing and Prescription Support for Vermont Blue Rx
Our Clinical Pharmacist, Amy Stoll, PharmD, works with our providers on specific prescription questions, drug authorizations, and patient panel projects. Amy is a board-certified ambulatory care pharmacist, certified diabetes educator and has a master's degree in public health. Learn more about the services our team can provide to you.