- To request EPSDT coverage for Drug use General Prior Authorization Form for most requests found below.
- To request EPSDT coverage (for Medical, Dental, Mental Health, and Behavioral Health) for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be at https://dvha.vermont.gov/forms-manuals/forms/clinical-prior-authorization-forms .
- For more information:
- Section of the Vermont Medicaid General Billing and Forms Manual
- Health Care Administrative Rules: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
- EPSDT services definition
Antipsychotic Medications (Pediatric) (Age <18 years old) Prior Authorization Form
Bone Resorption Inhibitors Injectable Prior Authorization Form
Brand Name Prior Authorization Form
Buprenorphine Spoke (OBOT) Prior Authorization
HUB (OTP) Buprenorphine Prior Authorization Form
CAR_T Therapy Prior Authorization Form
Cinqair Prior Authorization Form
Cystic Fibrosis Medication Prior Authorization/Order Form
Dupixent Prior Authorization Form
Enbrel Prior Authorization/Order Form
Fasenra Prior Authorization Form
Growth Stimulating Agents Prior Authorization/Order Form
Hepatitis C Treatment Prior Authorization Form
Humira Prior Authorization Form - Adult
Humira Prior Authorization Form - Pediatric Age<18 years old
Infliximab Prior Authorization Form
Long Acting Opioids Prior Authorization Form
Morphine Milligram Equivalent (MME) Safety Checklist Prior Authorization Request Form
Multiple Sclerosis Authorization/Order Form
Nutritional Prior Authorization
Oral Oncology Prior Authorization
Sickle Cell Disease Therapy Prior Authorization
Spinal Muscular Atrophy (SMA) Therapy Prior Authorization
Synagis Prior Authorization Form
90-Day Maintenance Requirement - Override Exception Form
Medicaid 340B Program Information (Under Form Type choose 340B Drug Program Enrollment)