Prior Approval/Pre-Authorization - VERMONT

BlueCard Members: To look up out-of-area member's Prior Approval/Pre-Authorization requirements, please use the Medical Policy Router.

Federal Employee Program Members: Only require Prior Approval on certain services, which are based on Medical Necessity. For a complete quote of benefit information, please contact The Federal Employee Program at 1-800-328-0365.

Prior Approval / Pre-Authorization - VERMONT

We provide benefits for certain services, drugs and supplies only if approval is obtained in advance. This ensures the procedures are diagnostically appropriate, medically necessary and cost effective.

Updated: 04-02-13

Procedure	Form	Send form to:
Chiropractic (after 12th visit)	Chiropractic Prior Approval Form (Chiropractic Plan of Treatment)	BCBSVT P.O. Box 186 Montpelier, VT 05601 or Fax to: Attention of Medical Services (802) 371-3491
Durable Medical Equipment, Orthotics, and Prosthetics	Durable Medical Equipment Prior Approval Form	BCBSVT P.O. Box 186 Montpelier, VT 05601 or Fax to: Attention of Medical Services (802) 371-3491
Inpatient Rehabilitation Pre-Certification	Inpatient Rehabilitation Pre-Certification Form	For most members* BCBSVT Medical Services P.O. Box 186 Montpelier, VT 05601 or Fax to: Attention of Medical Services (802) 371-3491
Medical Services Requiring Prior Approval	Medical Services Prior Approval Form	For most members* BCBSVT Medical Services P.O. Box 186 Montpelier, VT 05601 or Fax to: Attention of Medical Services (802) 371-3491
New England Health Plan (NEHP) Medical Services Requiring Referral Authorization	Medical Services Prior Approval Form	For most members* BCBSVT Medical Services P.O. Box 186 Montpelier, VT 05601 or Fax to: Attention of Medical Services (802) 371-3491
Radiology Services (Elective) - CT, CTA, MRI, MRA, MRS & PET scans	AIM Provider Portal Federal Employee Program Members do not require prior approval for outpatient diagnostic testing	Not applicable. Website, or Phone: 1-800-701-0080
Mental Health & Substance Abuse	Magellan Provider Portal	Not applicable. Website
Prescription Drugs Requiring Prior Approval	Express Scripts - Online Rx Prior Approval	Phone: 800-313-7879 FAX: (888) 255-1006
Prescription Drugs Requiring Prior Approval	Prescription Drug Prior Approval Forms	Phone: 800-313-7879 FAX: (888) 255-1006
Prescription Drugs Requiring Prior Approval for Federal Employee Program members	Federal RX Program	Phone: Caremark 800-624-5060
Quantity Limits	Express Scripts - Online Rx Prior Approval	Phone: 800-313-7879 FAX: (888) 255-1006
Quantity Limits	Quantity Limits Forms	Phone: 800-313-7879 FAX: (888) 255-1006
Step Therapy	Express Scripts - Online Rx Prior Approval	Phone: 800-313-7879 FAX: (888) 255-1006
Step Therapy	Step Therapy Forms	Phone: 800-313-7879 FAX: (888) 255-1006