- 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.
- 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
Forms
- 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
- Continuous Glucose Monitors
- Cystic Fibrosis Medication Prior Authorization/Order Form
- Dupixent Prior Authorization Form
- Enbrel Prior Authorization/Order Form
- Fasenra Prior Authorization Form
- General Prior Authorization
- Growth Stimulating Agents Prior Authorization/Order Form
- Hemophilia Factor 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
- Nucala Prior Authorization
- Nutritional Prior Authorization
- Oral Oncology Prior Authorization
- Semaglutide: Major Adverse Cardiovascular Event (MACE) Reduction
- Sickle Cell Disease Therapy Prior Authorization
- Spinal Muscular Atrophy (SMA) Therapy Prior Authorization
- Synagis Prior Authorization Form
- Ustekinumab Products Prior Authorization
- Xolair Prior Authorization
- Zepbound: Obstructive Sleep Apnea
- 90-Day Maintenance Requirement - Override Exception Form
- Medwatch Form (FDA)
- Medicaid 340B Program Information (Under Form Type choose 340B Drug Program Enrollment)