Prior Approval Requirement Listing
We do not allow benefits for services or supplies on the list below if you do not get approval in advance. In cases where Prior Approval is denied or not sought, you (the member) will have to pay the total charge for the services.
Procedures that Require Prior Approval
- Mental health or substance abuse treatment
- Plastic or cosmetic surgery (for example, abdominoplasty, lipectomy, blepharoplasty, breast reconstruction, otoplasty, panniculectomy, rhinoplasty or septorhinoplasty)
- Dental services (oral surgery, trauma, orthognathic surgery)
- UPPP/Somnoplasty
- Select durable medical equipment (DME) and those with a purchase price over $250, Click here for the DME Prior Approval form.
- Rehabilitation (cardiac/pulmonary/inpatient rehabilitation facility)
- Polysomnography (sleep studies) & MSLT
- Transplants (except kidney and cornea)
- Continuous passive motion (CPM) equipment
- Osteochondral Autograft Transfer System
- Outpatient, continuous glucose monitoring
- TENS units/neuromuscular stimulators
- Private duty nursing
- Home infusion therapy
- All CT, MRI, MRA, MRS and PET scans
- Orthotics/prosthetics
- Capsule endoscopy
- Chondrocyte transplants
- Medical nutrition for inherited metabolic disease
- Out-of-network services if you have a Vermont Health Partnership or a bluecare plan
- Non-emergency ambulance transport, including water or air ambulance transport
- Certain prescription drugs (current list of prescriptions)
- Certain surgical procedures (bariatric (obesity) surgery, gastric electrical stimulation, percutaneous vertebroplasty or vertebral augmentation)
- New procedures still considered investigational or experimental
Prescription Drugs
Medications without an NDC number (please provide name).
Drugs that have been on the market less than 12 months.
To get Prior Approval for prescription drugs, providers must submit the appropriate Approval Request Form for Prescription Drugs
The list of drugs that need Prior Approval changes from time to time. We will inform you of changes using newsletters and other mailings.
To check if a specific drug requires prior approval:
- ask your doctor or
- refer to the list of drugs that need prior approval by visting our website.
- you may also call our customer service department at the number on the back of your I.D. card.
Exclusions
We provide no prescription drug benefits for:
- refills beyond one year from the original prescription date;
- devices of any type other than prescription contraceptives, even though such devices may require a prescription order including, but not limited to: Durable Medical Equipment, prosthetic devices, appliances and supports (although benefits may be provided under other sections of your Contract);
- any drug considered to be Investigational;
- vitamins, except those which, by law, require a Prescription;
- drugs that do not require a prescription, except insulin, even if your doctor prescribes or recommends them; and
- nutritional formulae, except for up to $2,500 per year for "medical foods" prescribed for the Medically Necessary treatment of an inherited metabolic disease or those administered through a feeding tube.
Narcotics and antibiotics are limited to a 30-day supply.
