Summary
Effective January 1, 2027, NPF (likely a Blue Cross Vermont plan) is implementing significant pharmacy formulary changes including uptiers of three medications, addition of step therapy for Gemtesa, exclusion of 40+ brand-name drugs with generic/alternative options available, removal of Viread from the Healthcare Reform List (subject to deductible/cost-share), and new quantity limits on diabetic test strips, Omnipod, bowel prep kits, and Twist refill kits. Billing teams must update coverage rules, prior authorization workflows, and claims processing to reflect these exclusions and new quantity limits.
Get alerts when payers change rules like this one
We check Blue Cross Blue Shield of Vermont and other payers every day and email you when a change matches your specialty and state.
Get Blue Cross Blue Shield of Vermont alertsPolicy Monitoring is free. No card required.
What to do
by Jan 1, 2027 · 8 steps
01Billing team and providers must.
02Update the practice's formulary records and billing system to reflect all 40+ brand exclusions and uptiers listed in this policy.
03Implement step therapy requirement for Gemtesa—ensure billing system flags claims for Gemtesa requiring documentation of prior trial with darifenacin ER, fesoterodine ER, oxybutynin IR/ER, solifenacin, tolterodine IR/ER, trospium IR/ER, or mirabegron.
04Add quantity limits to billing/claims adjudication: diabetic test strips (100 strips per 30 days without insulin, 300 per 30 days with insulin), Omnipod (10 pods per 30 days), polyethylene glycol bowel prep kits (2 per 365 days), Twist refill kits (1 per 30 days).
05Confirm that Viread (tenofovir DF) and generic tenofovir DF are now subject to deductible and cost-share (removal from Healthcare Reform List).
06Note that patients currently on Epclusa, Harvoni, or Sovaldi may continue existing treatment regimens despite exclusion status.
07Front-desk staff should screen for alternative medication availability at time of insurance verification.
08Claims exceeding quantity limits or lacking step-therapy documentation will be denied or require manual review.
Original notice
Pharmacy Updates
bluecrossvt.org · Always check the source before changing claims.