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 AHS.DVHAMedicaidExceptions@vermont.gov 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.
- This rule can be found by going to our Adopted Rules page here: Adopted Rules | Agency of Human Services (vermont.gov) and then clicking on this link labeled “Medicaid Covered Services Rules (7100-7700).”
- See Rule 7104 of the Medicaid Covered Services Rules for more information about Requests for Coverage Exception.
- The Member Request for Coverage Exception form is used for adults age 21 and older.
Members Under Age 21
- To request coverage exception for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be found on the Clinical Forms and Prior Authorization Forms webpage.
- See section 5.2.1 of the Vermont Medicaid General Billing and Forms Manual for more information on EPSDT services
- Non-Covered Drug (use General Prior Authorization Form for most requests): Pharmacy Prior Authorization Request Forms and Order Forms | Department of Vermont Health Access