Vermont Medicaid Formulary: Preferred Drugs and Prior Authorization

The Vermont Medicaid formulary is the list of prescription drugs covered by Vermont Medicaid, built around a Preferred Drug List (PDL) that pharmacies can fill without extra steps and a set of non-preferred drugs that require prior authorization before the claim will pay. The program is run by the Department of Vermont Health Access (DVHA), with pharmacy claims administered under contract by Optum.¹

What the Preferred Drug List Covers

A drug on the PDL is “preferred,” meaning DVHA has evaluated it for both clinical effectiveness and cost and made it available without prior authorization.² Placement decisions run through the Drug Utilization Review Board (DURB), which is required by federal law to review drug use and report on what DVHA and its pharmacy benefit administrator are doing. In state fiscal year 2025, the board conducted 39 full new drug reviews and evaluated 12 biosimilars for possible formulary placement.³

DVHA publishes the current PDL and several supplemental coverage lists on its provider pharmacy portal, including the maintenance drug list and the high-investment carve-out list.⁴ Checking the current list is the fastest way to confirm whether a specific medication is preferred, non-preferred, or handled through a separate process.

Non-Preferred Drugs and Prior Authorization

Non-preferred medications can still be prescribed and dispensed, but the pharmacy or provider has to submit a prior authorization request first. DVHA’s target turnaround is 24 hours. If a member needs the medication immediately while the request is still pending, the pharmacy can process a 72-hour emergency override at the counter.²

Approval turns on whether the request meets clinical criteria. Some requests are approved automatically through an “auto-PA” look-back that checks a member’s history against the criteria without manual review. Prescribers can also submit through a provider portal with pre-populated authorization forms, and e-prescribing systems flag preferred alternatives at the point of ordering, which often heads off a denial before the prescription is written.²

Denials are not rare. The prior authorization denial rate reached 33.1% in SFY2025, driven partly by a wave of off-label requests for GLP-1 drugs used for weight loss.³ Beyond prior authorization, DVHA uses quantity limits, accumulation limits, and automated edits at the point of sale to catch problems before a claim pays.

What Vermont Medicaid Does Not Cover

A few boundaries are worth knowing before you fill a prescription:

Drugs prescribed solely for weight loss are not covered under the state plan. Off-label GLP-1 requests for weight loss (Ozempic and similar) are routinely denied.³
Over-the-counter melatonin, vitamin D, and antihistamines have not been covered since August 1, 2023.⁵
At-home COVID-19 test kits have not been covered since October 1, 2024.³

90-Day Supplies, Specialty Drugs, and Carve-Outs

Some medications come with rules about how they are filled rather than whether they are covered. DVHA’s maintenance drug category list identifies chronic-condition medications that must be filled in 90-day quantities rather than shorter intervals.⁴ If a maintenance drug is on that list, your pharmacy will fill it as a 90-day supply.

High-cost medications are handled through a separate high-investment carve-out drug list, most recently updated effective January 1, 2026.⁴ Drugs on the carve-out list are managed separately from the standard pharmacy benefit. Specialty drugs sit in their own category as well; they made up only 0.6% of claims in SFY2025 but 29% of gross drug spending, averaging $6,877 per prescription.³

Medications for Opioid Use Disorder

The formulary is structured to keep medications for opioid use disorder (MOUD) accessible, and the rules are more permissive than for the rest of the drug list. Methadone for substance use disorder requires no prior authorization. Suboxone Film and generic buprenorphine/naloxone tablets are available without prior authorization at doses up to 24mg in Hub settings and up to 16mg in Spoke settings. Narcan (naloxone) nasal spray also requires no prior authorization.²

There are no quantity limits on lower-dose buprenorphine formulations, so prescribers have room to induct and titrate new patients. Higher doses and non-preferred formulations like Zubsolv and Sublocade require prior authorization, but a provider can get approval by documenting cravings, acute withdrawal, or relapse.

Since the federal MAT Act took effect, the previously required X-waiver for buprenorphine is no longer in force. Any provider with a standard DEA controlled-substance license can prescribe buprenorphine for opioid use disorder without a separate registration.⁶ Vermont’s Hub-and-Spoke system connects nine regional Hubs (including methadone) with more than 87 Spoke sites where buprenorphine and other MOUD are prescribed, serving more than 6,000 people funded through Medicaid.

Claims Processing After the 2024 Cybersecurity Outage

If you had prescriptions rejected or authorization requests stuck in 2024, the reason may not have been your medication. A cybersecurity incident at Change Healthcare on February 21, 2024, took Vermont Medicaid’s pharmacy claims processing entirely offline. Staff could not access claims, process overrides, or handle prior authorizations.⁷ Claims processing resumed on March 18, 2024, and prior authorization capabilities were restored on August 7, 2024.³

Core utilization management functions, including edits, quantity limits, and prior authorizations, have since been restored to full operation. The Pharmacy Care Management program, a DVHA-Optum medication-adherence initiative that had enrolled 3,723 members covering 188 medications by the end of 2023, was suspended during the outage; as of October 2025, Optum was reimplementing the application, with resumption anticipated in the fourth quarter of 2025.³⁸ For members, that means the standard prior authorization process is fully back in place: if a drug is not preferred, expect your prescriber or pharmacy to submit a request, and expect an emergency 72-hour supply as a fallback if you need the medication right away.

1
Department of Vermont Health Access. Pharmacy Benefits Administrator
2
Vermont General Assembly. Prior Authorization Requirements for Medication Assisted Treatment for Opioid Use Disorder in the Vermont Medicaid Program
3
Vermont General Assembly. Pharmacy Best Practices and Cost Control Program Report (2025)
4
Department of Vermont Health Access. Drug Coverage Lists
5
Vermont General Assembly. Pharmacy Best Practices and Cost Control Program Report (2024)
6
Blueprint for Health. Hub and Spoke
7
National Association of State Procurement Officials. Change Healthcare Pharmacy Benefits Claims Processing Interruption for Vermont Medicaid
8
Medicaid.gov. Vermont Global Commitment to Health Annual Monitoring Report, January–December 2023