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Coverage Exceptions

Medicaid members who are 21 years old and older may request coverage of a service that Vermont Medicaid has not already determined to be a covered service. The request should be made using the Medicaid Coverage Exception Request form linked below.

Call the DVHA Exception Coordinator at (802) 241-0454 or email with questions.

Members Age 21 and Older

  • Member Request for Coverage Form
    • The Member Request for Coverage Exception form is used for adults age 21 and older.
      • See Rule 7104 of the Medicaid Covered Services Rules for more information about Requests for Coverage Exception.

Members Under Age 21