Vermont Medicaid Prior Authorization Form

Updated January 23, 2022

A Vermont Medicaid Prior Authorization Form is a document that is used to request Medicaid coverage for a non-preferred drug within the State of Vermont. In order for this request to be accepted, the prescriber must provide a proper medical justification for not prescribing a drug from the State-approved PDL (Preferred Drug List). On this page, you will find a downloadable PDF version of this form which can be either printed and filled out by hand, or filled out by computer using Adobe Acrobat or Microsoft Word. For more information, you can call the Goold Health Systems (GHS) Helpdesk at the phone number provided below.

Fax – 1 (844) 679-5366

Phone – 1 (844) 679-5363

Updated Preferred Drug List (PDL) – List of drugs pre-approved by the State

How to Write

Step 1 – Download the PDF version of this form here and open it with Adobe Acrobat or Microsoft Word.

Step 2 – Start filling out the form by entering the prescribing physician’s name, phone number, fax number, address, and office contact person into the indicated fields.

Step 3 – In the “Beneficiary” section, provide the patient’s name, Medicaid ID number, date of birth, and sex. If known, also enter the pharmacy name, pharmacy phone number, and pharmacy fax number.

Step 4 – Next, enter the appropriate HCPCS J-code or other code, and the “Administering Provider/Facility” name, NIP number, and Medicaid ID number.

Step 5 – Check the indicated box if this drug is provided under the DVHA’s 340B Drug program and requires the UD modifier.

Step 6 – Enter the name of the “Drug Requested,” its “Strength/Route/Frequency,” and the “Length of Therapy.”

Step 7 – Below that, write the “Patient’s diagnosis for use of this medication” in the indicated field.

Step 8 – You will then be asked to describe any previous medical conditions, allergies, or other medical information that have made this request necessary.

Step 9 – Answer yes or no to the question, “Was patient seen by any other provider for this condition?” If the answer is yes, enter the other provider’s specialty into the appropriate space.

Step 10 – If the patient has tried any preferred medications that failed in treatment of their current diagnosis, enter the name, reason for failure, and dates of trial for each applicable drug.

Step 11 – You are then asked to enter the name of procedure, the finding (result/value), and the date of testing for any laboratory tests pertinent to this request.

Step 12 – Beside “Other Information/Comments,” write any additional information that supports your clinical justification for making this request.

Step 13 – Print the form.

Step 14 – Provide the “Prescribers Signature” and the “Date” where indicated.

Step 15 – Fax the completed form to the correct directory.