Blue Cross Blue Shield Vermont
Subscriber Contract Documents

To view the documents corresponding to your plan, click on your participating plan.
• BlueCare
• BlueCare Options
• Comprehensive
• Other Group Specific Documents
• Plan J
• Catamount Blue

• Saint Michael's College
• UVM (University of Vermont)
• Vermont Blue 65/Medi-Comp
• Vermont Freedom Plan
• Vermont Health Partnership
BlueCare
BlueCare Certificate - 280.114
Deductible Carryover Rider - 280.331
Domestic Partnership Rider - 280.121
HSA BlueCare Rider - 280.218
Naturopathic Physicians Endorsement - 280.233
Prescription Drug Benefit Rider - 280.122
Three-tier Prescription Drug Benefits Rider - 280.188
Vision Examination Rider - 280.119
Vision Materials Benefit Rider - 280.117

BlueCare Options
BlueCare Options Certificate of Coverage - 280.115
Deductible Carryover Rider - 280.231
Domestic Partnership Rider - 280.121
Naturopathic Physicians Endorsement - 280.233
Prescription Drug Benefit Rider - 280.122
Three-tier Prescription Drug Benefits Rider - 280.188
Vision Examination Rider - 280.119
Vision Materials Benefit Rider - 280.117

Comprehensive
Benefits Exclusion Rider - 280.228
Comprehensive Certificate of Coverage - 210.21
Comprehensive Plan Safety Net Benefits Rider - 280.215
Comprehensive Plus Rider - 280.205
Deductible Carryover Rider - 280.230
Domestic Partnership Rider - 280.76
Health Reimbursement Account Rider - 280.212
Health Reimbursement Account Rider with Preventive Care Benefits- 280.226
Health Savings Account Program Rider - 280.214
HSA Blue Rider w/ Preventive Care Benefits - 280.223
Medical Savings Account Program Rider - 280.181
Naturopathic Physicians Endorsement - 280.232
Open Network Mental Health and Substance Abuse Rider - 280.175
Outpatient Procedures Rider S - 280.172
Prescription Drug Benefit Rider - 280.171
Rider Removing Precertification Program - 280.179
Rider Removing Prescription Drug Coverage - 280.198
Three-tier Prescription Drug Benefits Rider - 280.187
Waiver of Waiting Periods - 280.162

Other Group Specific Documents
City of Burlington Benefits Rider - 280.190
Benefits Rider for Mt. Ascutney Hospital Employees - 280.222

Plan J
Deductible Carryover Rider - 280.230
Domestic Partnership Rider - 280.76
Naturopathic Physicians Endorsement - 280.232
Open Network Mental Health and Substance Abuse Rider - 280.175
Plan J Certificate of Coverage - 210.20
Prescription Drug Benefit Rider - 280.171
Rider Removing Precertification Program - 280.179
Three-tier Prescription Drug Benefits Rider - 280.187
Waiver of Waiting Periods - 280.162

Saint Michael's College
Naturopathic Physicians Endorsement - 280.232
Prescription Drug Benefit Rider - 280.171
Saint Michael's College Exclusive Provider Plan Certificate of Coverage - 280.200
Saint Michael's College Benefits Rider 280.202
Three-tier Prescription Drug Benefits Rider - 280.187
Waiver of Waiting Periods - 280.162

UVM (University of Vermont)
Domestic Partnership Rider - 280.76
Naturopathic Physicians Endorsement - 280.232
Prescription Drug Benefit Rider - 280.171
Three-tier Prescription Drug Benefits Rider - 280.187
Vermont Health Partnership Handbook and Certificate of Coverage for UVM- 284.66
University Of Vermont Benefits Rider - 280.189
University Of Vermont JY Benefits Rider - 280.113
UVM VHP Benefits Rider N - 280.216
University Of Vermont Dental Benefits Rider - 280.199
University of Vermont Medi-Comp Rider - 280.112
University of Vermont Vermont Freedom Plan Benefits Rider - 280.225
Waiver of Waiting Periods - 280.162

Vermont Blue 65/Medi-Comp
Medi-Comp Plan A - 280.54
Medi-Comp Plan C - 280.55

Vermont Freedom Plan
Benefits Exclusion Rider - 280.228
Casella Vermont Freedom Plan Certificate of Coverage - 280.204
Deductible Carryover Rider - 280.230
Domestic Partnership Rider - 280.76
Individual HSABlue Nongroup Health Savings Account Rider - 280.220
Naturopathic Physicians Endorsement - 280.232
Open Network Mental Health and Substance Abuse Rider - 280.175
Prescription Drug Benefit Rider - 280.171
Rider Removing Prescription Drug Coverage - 280.198
Three-tier Prescription Drug Benefits Rider - 280.187
Vermont Freedom Plan Certificate of Coverage - 280.40
Vermont Freedom Plan Nongroup Benefits Rider - 280.195
Vermont Freedom Plan Handbook - 284.215
Vermont Freedom Plan Safety Net Benefits Rider - 280.196
Vermont Freedom Plan Safety Net Benefits Rider w/ No Prescription Drug Coverage - 280.197
Waiver of Waiting Periods - 280.162

Vermont Health Partnership
Application of Waiting Periods Rider - 280.59
Deductible Carryover Rider - 280.230
Domestic Partnership Rider - 280.76
Naturopathic Physicians Endorsement - 280.232
Prescription Drug Benefit Rider - 280.171
Three-tier Prescription Drug Benefits Rider - 280.187
Vermont Health Partnership Certificate of Coverage VEHI - 280.98
Vermont Health Partnership Handbook and Certificate of Coverage - 280.52
Vision Materials Benefit Rider - 280.53

Catamount Blue
Catamount Blue Certificate
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