Copayments are never required for the following beneficiaries:
Individuals in a long-term care facility
Those under age 21
Those who are pregnant or in a 60 day post-pregnancy period
$1.00 for prescriptions costing less than $30.00
$2.00 for prescriptions costing $30.00 or more, but less than $50.00
$3.00 for prescriptions costing $50.00 or more
$3.00 per visit for dental services
preventive services do not require a copay
$3.00 per day per hospital for outpatient services
Chiropractic services are limited to treatment by means of manual manipulation of the spine for the correction of a misalignment of the spine.
Coverage is limited to ten (10) treatments per calendar year per beneficiary.
Treatments beyond ten per year require prior authorization.
The adult dental benefit is limited to $1,000 per beneficiary per calendar year.
Allowing up to two visits for preventive services per calendar year that do not count towards the $1000 annual maximum dollar limit.
Non-covered services include; cosmetic procedures; and certain elective procedures, including but not limited to: bonding, sealants, periodontal surgery, comprehensive periodontal care, orthodontic treatment, processed or cast crowns and bridges.
Prior authorization is required for most special dental procedures.
One comprehensive eye exam and one intermediate eye exam within a two year period,
Two intermediate eye exams within a two year period
Hearing aids are limited to one hearing aid per ear every three years for specified degrees of hearing loss.
Lab Tests and X-rays or Imaging
The following outpatient high-tech imaging services require prior authorization:
Computed tomography (CT) (previously referred to as CAT scan);
Laboratory services for urine drug testing is limited to eight (8) tests per calendar month.
This limitation applies to tests provided by professionals, independent labs and hospital labs for outpatients.
Exceptions to this limitation require prior authorization.
Services are limited to those specified in protocols for licensure and reviewed and accepted by the State of Vermont, Director of the Office of Professional Regulation, and are services covered by Medicaid.
Short-term Skilled Nursing Facility (SNF) stay that is limited to not more than 30 days per episode and 60 days per calendar year.
Administratively necessary or court ordered tests are not covered, unless they are medically necessary.
Podiatrists’ services are limited to non-routine foot care.
Physical Therapy, Occupational Therapy and Speech or Language Therapy
Services are limited to thirty (30) therapy visits per calendar year, and include any combination of physical therapy, occupational therapy and speech/language therapy.
Prior authorization beyond 30 therapy visits in a calendar year will only be granted to beneficiaries with the following diagnoses: