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
November 4, 2025
Prior Authorization Tool Maintenance
The Prior Authorization tool will be unavailable from 7am Sunday, November 23 through 7am Monday, November 24, 2025 for routine maintenance. During this time, if you need to request a prior authorization you will need to submit on a State of Vermont Uniform Medical Prior Authorization Form by fax to (866) 387-7914.
All other functions on the Provider Resource Center such as eligibility, claims, and provider vouchers will be available during this time.
November 1, 2025
Wegovy Coverage for the Prevention of Major Adverse Cardiovascular Outcomes
As a reminder from our previous notification, GLP-1 medications that are FDA-approved for weight loss will no longer be covered effective January 1, 2026, for most Blue Cross VT plans. We will continue to cover GLP-1 medications that are FDA-approved for Type 2 diabetes, with prior authorization. In addition, Wegovy may be covered for the prevention of certain obesity-related major adverse cardiovascular events (MACE). The criteria for MACE prevention are based on the SELECT trial.
For more information on coverage of GLP-1 medications for MACE, view our notice.
November 1, 2025
Prior Authorizations: Act 111 Changes for January 1, 2026
Beginning January 1, 2026, prior authorizations for medically necessary services, excluding prescription drugs or out of network services, will be waived for eligible members when ordered by any primary care provider that has a contract with us.
For more details on the changes and submitting claims, view our notice.
November 1, 2025
Medical and Payment Policy Updates
Effective January 1, 2026, payment and medical policy updates take effect. Please be sure to review the upcoming changes.
November 1, 2025
Pharmacy Updates
- Infliximab product medical benefit drug changes for January 1, 2026
- Inflectra (Q5103) becomes preferred and no longer requires prior authorization.
- Avsola (Q5121) remains the same (preferred) and does not require prior authorization.
- Remicade/infliximab (J1745) requires prior authorization.
- NPF Formulary changes for January 1, 2026
- All members and providers affected by formulary changes received a letter in October 2025.
- GLP-1 medications reminder: The GLP-1 medications Zepbound, Wegovy, and Saxenda are excluded for the indication of weight loss for members on Qualified Health Plans, Blue Edge Business, and most employer plans as of January 1, 2026. Members who continue to use these medications will be responsible for the full cost.
- Brand medications excluded on the formulary (must use generic equivalent)
- Adderall XR
- Aldactone
- Aptiom
- Brilinta
- Copaxone 40mg/mL
- Dymista
- Entresto
- Medications excluded with alternatives
- Adalimumab-adbm and Amjevita (biosimilars to Humira) will be excluded. The alternative is Simlandi, which is currently on formulary. Patients can be switched prior to January 1,2026.
- Wezlana (biosimilar to Stelara) will be excluded. The alternative is Yesintek, which is currently on formulary. Patients can be switched prior to January 1, 2026.
- Ajovy will be excluded. Emgality is moving to preferred on January 1, 2026. Aimovig, Nurtec, and Qulipta will continue to be on formulary.
- Candesartan
- Dayvigo
- Doxycycline 40mg (Rosacea)
- Estrogel 0.06%
- Omeclamox Pak
- Up Tier
- Meter and Test Strips (Lifescan mftr) will move to nonpreferred. Patients can switch to Contour (currently a preferred option) or Freestyle/Precision (will be preferred on January 1, 2026).
- Wegovy for the indication of Major Adverse Cardiovascular Events (MACE)
- Depen Titra
- Supprelin LA
For the most up to date information on BCBSVT and NPF formularies, visit our Lists of Covered Medications.
November 1, 2025
Billing Requirements for National Drug Code
Beginning January 1, 2026, the billing requirement for reporting a National Drug Code (NDC) on professional claims will be fully enforced. It is required to report an NDC along with the unit of measure and quantity on the claim submission. Incomplete or inaccurate claims submissions not meeting the requirements will be denied.
View our notice for more detail on this requirement.
November 1, 2025
Free Provider Psychiatric Consultations
The Vermont Consultation & Psychiatry Access Program (VTCPAP) provides free, fast psychiatric consultations to registered practices that care for pediatric and perinatal patients. Providers can receive peer-to-peer support on screening, diagnosis, and treatment planning from licensed social workers or psychiatrists. Calls are returned within 30 minutes during business hours. Learn more about the service at vtcpap.com.
November 1, 2025
Identification Card Change
The Blue Cross and Blue Shield Association has begun making changes to member ID cards. While the health plan product type (EPO, PPO, HMO) will remain, the suitcase logo will be phased out, along with additional small changes. We’ll provide more details in the coming months.
November 1, 2025
Claims Xten-Select Upgrade
An update to ClaimsXten-Select™ is scheduled for Thursday, January 1, 2026. Review the notice to understand the upcoming changes.
November 1, 2025
Verisys Reminder
Verisys, a national credentials verification organization, is responsible for primary source verification for our credentialing and re-credentialing process.
Verisys may outreach to you directly if additional actions are required to complete the primary source verification. To ensure your network status isn't interrupted, please respond immediately if they reach out to you.
One way to avoid outreach from Verisys is to ensure your Council for Affordable Quality Healthcare (CAQH) information is current and attested. You can set up, view, and update your CAQH ProView™ account at https://proview.caqh.org/. Check your CAQH account to ensure:
- All information is current and that current copies of malpractice insurance, current licensure, DEA, etc. are successfully uploaded.
- Your provider status is at Re-Attestation.
- Blue Cross and Blue Shield of Vermont is authorized to receive your provider data from CAQH.
If you are unable to access CAQH or have questions regarding the primary source verification process, contact Verisys Customer Service at (855) 743-6161, Monday-Friday from 8 a.m. to 8 p.m. ET. If you are a first-time user, you can find an online demonstration of the application process at https://proview.caqh.org/.
November 1, 2025
Prior Approval List Updates
The prior approval list has been updated to reflect the addition and removal of codes, effective January 1, 2026. Review our notice for details on the updated codes.
November 1, 2025
Routine Code Maintenance
Review our notice for details on the implementation of new and revised codes, effective January 1, 2026.
November 1, 2025
Preventive Care Guide Updates
The preventive care guide is updated with additional codes. Review our notice for more details on the added codes.
November 1, 2025
Provider Handbook Updates
Updates to the provider handbook have been made to the following sections: Claim Specific Guidelines, Act 111 Primary Care Provider Waiver of Prior Authorization, Modifiers, Blue Cross VT/The Vermont Health Plan Contracts, Provider Voucher, and 835 Transactions.
November 1, 2025
2026-2027 Electronic Fund Transfer Payment Schedule
Electronic Fund Transfer (EFT) payments are made on Fridays for that Tuesday’s provider voucher(s). When a holiday falls on a Friday, the EFT will occur on the following Monday. EFT payments will be made on Mondays for the following holidays next year:
- Juneteenth
- Independence Day
- Christmas Day
- New Year's Day
November 1, 2025
2026 Holiday Schedule
Blue Cross VT and Carelon are closed January 1 and January 19. Please review our 2026 holiday schedule, including information for our partners.
October 1, 2025
Medical and Payment Policy Updates
Effective December 1, 2025, payment and medical policy updates go into effect. Please be sure to take time to review them.
October 1, 2025
Vaccine Coverage
Blue Cross and Blue Shield of Vermont is committed to ensuring access to vaccines that protect individuals and communities from serious illness. The decision to receive a vaccine is made between patients and their health care providers, and we remain committed to maintaining rigorous, evidence-based processes to evaluate coverage policies.
We will continue covering all immunizations that were recommended by the Advisory Committee on Immunization Practices (ACIP) on January 1, 2025, with no cost-sharing through 2026.
October 1, 2025
Pharmacy Updates
Starting January 1, 2026, new formulary change will go into effect. More information will be shared next month, so you'll know what to expect and how to plan ahead.
October 1, 2025
2026 Coverage Changes for GLP-1 Drugs FDA-Approved for Weight Loss
Coverage Changes
Beginning January 1, 2026, Blue Cross VT will no longer cover prescription GLP-1 drugs that are FDA-approved for weight loss, such as Wegovy®, Zepbound®, and Saxenda®, for Qualified Health Plan (QHP), Blue Edge Business, and Vermont Education Health Initiative (VEHI) members.
Blue Cross VT and VEHI members who are impacted by this coverage change will be notified by mail. If they choose to continue using GLP-1 medications for weight loss 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 our member FAQ document.
Coverage Not Impacted
Coverage for GLP-1 drugs will continue for all plan members who meet the following criteria:
- Members with diagnosed Type 2 diabetes.
- Adult members with established cardiovascular disease and obesity who are prescribed Wegovy® to reduce the risk of major adverse cardiovascular events (MACE).
- Potential Exception: Our large group clients in our fully insured products and our Blue Edge Classic clients have the option to continue coverage for GLP-1s for weight loss in their plan.
October 1, 2025
Risk Coding Initiative
Our Risk Adjustment Data Validation audit (RADV) with our vendor Reveleer is coming to a close. Please submit any current medical record requests to them as soon as possible.
As early as October, you may start receiving medical record requests from our new vendor, Datavant. These requests are different from the RADV audit; they are for our Risk Coding Initiative project that takes place in the fall, winter, and spring. If you receive a medical record request from them, please be sure to submit the requested records.
October 1, 2025
ICD-10 Code Updates
Every October 1, ICD-10-CM codes undergo major updates, including the additions and deletions of codes and changes to code descriptions and guidelines. Recent additions include the appearance of COVID-19, the necessity of “in remission” codes for certain types of cancers, and for atrial septal defects.
It is important to use the most up-to-date code set to avoid incorrectly describing a member’s medical condition, impacting claim denials and additional work for your office staff. Check out our new coding tips sheets.
October 1, 2025
Prior Approval List Update
Code Added: Code 0047U was previously omitted from the Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management Medical Policy. The code has been added to our prior approval list.
October 1, 2025
Preventive Care Guide Updates
The preventive care guide has additional codes for the Antiretroviral Therapy for Prevention of Human Immunodeficiency Virus (HIV) Infection: Pre-Exposure Prophylaxis (PrEP) and Breast Pump and Related Supplies sections.
October 1, 2025
Provider Handbook Updates
The following sections of the provider handbook have been updated: Claim Specific Guidelines, Dental Care, and Blue Cross VT/The Vermont Health Plan (TVHP) Contracts.
October 1, 2025
Fourth Quarter CAA Directory Validation
Important Reminders
- Fourth Quarter CAA Directory validations will be released on or around October 4, 2025.
- You must complete the directory validation by Tuesday, November 4, 2025, or you will be removed from our provider directory and risk possible contract termination.
- The CAA directory validation is sent by email from noreply@onbaseonline.com.
- If you receive more than one email, please respond to all emails received. Some providers have multiple providers files, and therefore, multiple verifications need to occur.
- If your practice was removed from the network directly due to non-response of a previous quarterly validation, this is your opportunity to be added back into the network directory.
Details about the CAA Directory Validation and instructions to complete the process are located on the 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.
August 29, 2025
Supervised Billing Reminder
Supervised billing is generally not allowed. Providers who render care to our members must be licensed, credentialed, and enrolled with Blue Cross and Blue Shield of Vermont. Submitted claims must report the provider who rendered the care to the member, using their individual National Provider Identifier.
Exceptions to this are: Physical Therapy Assistants, Occupational Therapy Assistants, and Mental Health/Substance Use Disorder (MHSUD) Trainees. Details on the requirements for Therapy Assistants and MHSUD Trainees are in our Provider Handbook.
August 29, 2025
Medical and Payment Policy Updates
Review the payment and medical policy updates that go into effect November 1, 2025.
August 29, 2025
Quality Policy Update
The Accessibility of Services and Provider Administrative Service Standards policy has been updated. It includes best practice revisions to After-Hours Care Standards for PCP and Specialty Offices and a new Practitioner Access Enhancement section. Please review the changes to ensure alignment with the updated standards.
August 29, 2025
Telemedicine for College Students or Members Residing Outside of Vermont
If you have a current patient moving from Vermont, and you plan to continue care using telemedicine, you must possess appropriate licensure in all states where the patient receives the care. Full details related to the requirements of Telemedicine and billing for these services are available in our Telemedicine (CPP_03) Payment Policy.
August 29, 2025
Reminder: Use of Third-Party Billers/Vendors
Third-party billers (or vendors) are defined as those entities/persons who are:
- Not physically located at a provider or group office
- Not direct employees of the provider or group
- Those submitting claims or following up on accounts on behalf of the provider or group and have a business associate relationship with the provider or group. Please note that the provider or group should be prepared to provide proof of a business associate relationship with the biller/vendor upon request.
For information to be released, the provider or group must authorize third-party billers (or vendors) with us. Additional details, including the steps needed for granting access are located in our Provider Handbook, in Section 6.1 General Claim Information.
August 29, 2025
Provider Handbook Updates
The provider handbook has been updated in various sections, including Section 4 on Integrated Health Services, Section 6.7 for Claim Specific Guidelines, and Section 6 on Member Liabilities, among others.
August 29, 2025
Surcharges and Convenience Fee
Providers must have a fee-free way to collect member liabilities, regardless of whether a member is using a check, credit card, or debit card. Additionally, providers may not impose credit card surcharges or other fees on members using either a personal debit card or an HSA/HRA issued debit card. A member should never be responsible for any additional fees beyond their reported liability.
August 29, 2025
Operational Reminders for Working with Us
To work more effectively and efficiently together, we have outlined different operational reminders about claims, appeals, and inquiries. Check out our document for detailed information.
July 31, 2025
Medical and Payment Policy Updates
View the payment and medical policy updates that go into effect October 1, 2025.
July 31, 2025
Pharmacy Updates
Generic Qsymia (Topiramate/phentermine) is now available and added to formulary as a Tier 1 generic.
July 31, 2025
Mental Health & MHSUD Medication Management Support with Valera Health
Through our partnership with Valera Health, they will work with you to ensure your patients get the care they need sooner, as well as ensure the patient’s medications are working effectively. Learn more about Valera Health and how their services can support you and our members at www.valerahealth.com.
July 31, 2025
Upcoming Holiday Closure
We will be closed on Monday, September 1, 2025, in observance of Labor Day. We will reopen for normal business hours on Tuesday, September 2, 2025.
July 31, 2025
Provider Handbook Updates
The provider handbook has been updated to reflect changes in effect for the coding validation review process, as well as where to access our current clinical practice guidelines.
July 31, 2024
Prior Approval List Changes
Review the upcoming changes to our list of services, equipment, and supplies requiring prior approval.
Monthly Newsletters
Adaptive Maintenance Newsletters
Our monthly provider e-newsletter is our primary source for all notices and updates. It replaces the individual notices you used to receive. If there are 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.