This measure is important because it tracks the exception requests reviewed by the Pharmacy, Clinical Integrity and Clinical Operations Units and will provide data to support a more efficient and improved clinical review of non-covered codes. The exception request process allows a Vermont Medicaid member, 18 years of age or older, to request coverage for non-covered services or items.

This measure tracks and monitors non-covered code request volumes, clinical category of exception requests, and the clinical review determination of exception requests.  Monitoring the request trends of non-covered codes will allow DVHA to:

•    consider code coverage in a timely approach, 
•    ensure access to services, and 
•    assess service coverage changes and resulting exception request volume increases, in a specific category of service, to support the delivery of quality and cost-effective health care services.   

The data and trendline demonstrate that the majority of exceptions requests received continue to represent non rebate pharmacy medications for this quarter with one request for medical service. CY25 Q1 data reveals all the exception requests were approved this quarter. Exception request volumes are still trending low for this quarter and have remained at 5 requests each quarter for the last three quarters.
 

Narrative Updated:  04/10/2025
 

• DVHA Exceptions Coordinator
• DVHA Clinical Services Team:  Pharmacy Unit, Clinical Integrity Unit & Clinical Operations Unit
• DVHA Chief Medical Officer
• DVHA Enrolled Providers
• DVHA Member Provider Services Unit
• DVHA Fiscal Agent, Gainwell