RegAlertReport · DFR · 22 Oct 2026
MVP Health Care Responses to the Vermont Prior Authorization Attestation Form (2026)
MVP Health Care reviewed prior authorization (PA) requirements through its Medical Management, Pharmacy & Therapeutics, and Clinical Operations Committees, using at least a 90% approval rate as a threshold for routine approval. It may add or eliminate PA requirements during a plan year. MVP added PA for medical oncology drugs effective January 1, 2024, terminated its advanced imaging PA contract with EviCore in April 2025 (removing 312 codes), and listed numerous CPT, HCPCS, and drug code additions and removals effective throughout 2025.
MVP Health Care Responses
Vermont Prior Authorization Attestation Form (2026)
Questions:
The below questions apply to health plans as defined in 18 V.S.A. 9418(a)(8) (including third party administrators, to the extent permitted under federal law):
1. Has the health plan reviewed the list of medical procedures and medical tests for which it requires prior authorization (PA) at least once during the proceeding plan year and eliminated the PA requirements for procedures and tests for which such a requirement is no longer justified or for which requests are routinely approved with such frequency as to demonstrate that the PA requirement does not promote health care quality or reduce health care spending to a degree sufficient to justify the administrative costs to the plan?
a. What is the health plan’s timeline for reviewing and eliminating prior authorization requirements? In answering this question, please provide the dates for the two most recent review cycles.
MVP Response: MVP continuously brings our clinical policies and data through our independent, physician run committee process. Below is a list of meeting dates, by MVP committee, where relevant PA policies and criteria were reviewed.
| 2025 | ||
|---|---|---|
| Medical Management Committee | Pharmacy & Therapeutics Committee | Clinical Operations Committee |
| 01/16/2025 | 01/16/2025 | 02/03/2025 |
| 02/20/2025 | 03/20/2025 | 05/05/2025 |
| 03/20/2025 | 05/15/2025 | 08/04/2025 |
| 04/17/2025 | 06/19/2025 | 11/03/2025 |
| 05/15/2024 | 07/17/2025 | |
| 06/19/2025 | 09/18/2025 | |
| 08/21/2025 | 10/16/2025 | |
| 09/18/2025 | 11/20/2025 | |
| 10/16/2025 | ||
| 11/20/2025 | ||
| 12/18/2025 |
b. Does the health plan ever add/eliminate PA requirements during a plan year (as opposed to between plan years)? Please explain.
MVP Response: MVP may add or eliminate PA requirements during a plan year. As previously stated, MVP does not just review the PA data once a year, so if a trend is identified, removal of PA requirements may occur at any time during the year.
c. What are the standards used by the health plan to evaluate PA requirements as outlined in 18 V.S.A. § 9418b(h) (including the thresholds the health plan considers in looking for routinely approved PAs, how the health plan determines whether PAs are promoting health care quality or reducing health care spending to a degree sufficient to justify the administrative costs to the plan)?
MVP Response: MVP considers multiple factors:
-
Volume (those test & procedures with sufficient volume to reliably assess PA value)
-
PA approval percentage (at least a 90% approval rate)
-
Updates to standard of care and current literature supporting PA or removal
-
Appeal and overturn rates
-
Regulatory Requirements, drug safety, and quality of care are also weighed for removal of utilization management
-
Delineation of impact of PA on health care spend to a degree sufficient to justify administrative costs to the plan (quantitative - plan ROI including review cost /excluding alternative care costs)
To the extent that the plan balances factors such as medical literature, quality, and cost (or others included in answer to Q1C), please explain the weight applied to each factor.
MVP Response: In general, equal weighting is applied to each factor, but weighting can vary depending on the specific type of treatment, procedure, or drug therapy. For example, in instances where there are clear clinical or quality standards that need to be followed, those are prioritized regardless of cost.
d. Does the health plan take into account the administrative burden of PAs on health care providers and patients and whether the administrative barriers to submit PAs may inhibit access to medically necessary care? Please explain.
MVP Response: MVP does evaluate the PA volume by provider and reviews utilization trends for certain services to ensure medically necessary care is being provided. MVP also does receive feedback from our participating providers and has modified and/or removed PA on specific services based upon their feedback.
Explain how provider administrative burden is weighted against other factors when deciding whether to apply a PA to a given service. What assumptions does the plan make with respect to the administrative burden associated with a PA requirement in terms of provider/patient time spent submitting the request, cost to providers (administrative staff, time spent on paperwork instead of with patients), member impact (potential second visit, adverse medical consequences as result of deferred/delayed care).
MVP Response: Improving member experience and meeting their healthcare needs are central to MVP’s core values. The organization strives to reduce unnecessary administrative burden on providers, and any resultant friction it may cause for members’ experience. When implementing a PA program, MVP seeks the minimum necessary information to meet the clinical standards of care or quality recommendations.
Importantly, any PA requirements also add costs and burden for MVP. These programs require additional policy development, systems configuration, IT investments, and additional staffing to support the numerous phone calls, provider and member communications, and internal/external appeals. State and federal medical loss ratio (MLR) requirements effectively cap what MVP can spend on non-medical, administrative costs, including those described here.
To attract and retain members, MVP must keep its administrative costs as low as possible to offer the most competitively priced products. Similarly, member experience also drives consumer decisions on whether to stay with MVP, or to switch health plans. So, it’s not in MVP’s interest to incur unnecessary administrative costs or establish burdens and barriers that diminish member or provider experience. When MVP implements a PA requirement, there are very clear and obvious quality, efficacy, and cost related reasons for doing so.
MVP is also constantly exploring new innovations and investments that can reduce this administrative burden for all parties. Online provider portals, electronic health record systems, and automation provide endless opportunities to ease the manual paperwork, phone calls, and any other associated administrative costs.
Lastly, alternative provider payment models provide opportunities that benefit providers, members, and health plans alike. MVP is actively working with its provider network partners to establish new capabilities and advance models that empower and incentivize providers in different ways. Ultimately, these models can delegate more clinical autonomy to provider partners by establishing a shared commitment around costs, quality, and efficacy of member treatment.
2. What medical procedures and tests had PA requirements eliminated or added during the preceding plan year and what was the rationale for changing those requirements?
MVP Response: MVP added prior authorization to Medical Oncology drugs as of January 1st, 2024. The full List of codes is available upon request. Additionally, the chart below represent all Medical and Pharmacy Prior authorization changes as of January 1st, 2025.
MVP terminated the advanced imaging PA contract with EviCore as of April 2025. This termination accounts for 312 code removals. Due to the global nature of the contract and service termination, these 312 codes are not represented below.
MVP Health Care Responses
Vermont Prior Authorization Attestation Form (2026)
| CPT Code | Service (Procedure) | CHANGE | PRIOR AUTH | Effec. Date | LOB |
|---|---|---|---|---|---|
| 36465 | Endovenous ablation therapy of incompetent extremity vein, inclusive of all imaging guidance and monitoring; first vein treated | ADD | Prior Auth | 7/1/2025 | ALL |
| 36466 | Endovenous ablation therapy of incompetent extremity vein; second and subsequent veins treated in same session | ADD | Prior Auth | 7/1/2025 | ALL |
| 44135 | Intestinal allotransplantation | ADD | Prior Auth | 9/1/2025 | ALL |
| 89290 | Biopsy, oocyte(s) or embryo(s), microtechnique | REMOVE | Prior Auth | 1/1/2023 | ALL |
| 89291 | Biopsy of embryo for preimplantation genetic diagnosis, additional processing | REMOVE | Prior Auth | 10/1/2024 | ALL |
| 90382 | Enflonsia | REMOVE | Prior Auth | 9/18/2025 | ALL |
| 0421T | Transcatheter mitral valve annulus reconstruction, including placement of prosthesis (Category III CPT) | ADD | Prior Auth | 8/1/2025 | ALL |
| C9174 | Injection, fosnetupitant (facility HCPCS code) | ADD | Prior Auth | 10/1/2024 | ALL |
| C9305 | Nipocalimab-aahu (IMAAVY), facility HCPCS code | ADD | Prior Auth | 7/1/2025 | ALL |
| C9306 | Facility HCPCS code for newly approved biological product (verify current CMS descriptor) | ADD | Prior Auth | 10/1/2025 | ALL |
| E0658 | Garment for pneumatic compressor, custom fabricated | ADD | Prior Auth | 10/1/2025 | ALL |
| E0659 | Pneumatic appliance, custom fabricated garment | ADD | Prior Auth | 10/1/2025 | ALL |
| E1022 | Manual wheelchair accessory, power seating system | ADD | Prior Auth | 10/1/2025 | ALL |
| E1023 | Wheelchair accessory, actuator/motor for power seating system | ADD | Prior Auth | 4/1/2025 | ALL |
| E1032 | Power wheelchair accessory, expandable controller | ADD | Prior Auth | 4/1/2025 | ALL |
| E1033 | Power wheelchair accessory, alternative control interface | ADD | Prior Auth | 4/1/2025 | ALL |
| E1034 | Power wheelchair accessory, electronic interface component | ADD | Prior Auth | 4/1/2025 | ALL |
| E1803 | Dynamic adjustable elbow extension/flexion device | ADD | Prior Auth | 4/1/2025 | ALL |
| E1804 | Dynamic adjustable wrist extension/flexion device | ADD | Prior Auth | 1/1/2025 | ALL |
| E1807 | Dynamic adjustable forearm pronation/supination device | ADD | Prior Auth | 1/1/2025 | ALL |
| E1808 | Dynamic adjustable finger extension/flexion device | ADD | Prior Auth | 1/1/2025 | ALL |
| E1813 | Dynamic adjustable knee extension/flexion device | ADD | Prior Auth | 1/1/2025 | ALL |
| E1814 | Dynamic adjustable ankle extension/flexion device | ADD | Prior Auth | 1/1/2025 | ALL |
| E1822 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, mechanical, terminal range of motion, elbow | ADD | Prior Auth | 1/1/2025 | ALL |
| E1823 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, wrist/finger | ADD | Prior Auth | 1/1/2025 | ALL |
| E1826 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, knee | ADD | Prior Auth | 1/1/2025 | ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| E1827 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, ankle | ADD | Prior Auth | 1/1/2025 ALL |
|---|---|---|---|---|
| E1828 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, elbow | ADD | Prior Auth | 1/1/2025 ALL |
| E1829 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, wrist | ADD | Prior Auth | 1/1/2025 ALL |
| E1832 | Dynamic adjustable soft tissue stretching device, low load prolonged stretch, toe | ADD | Prior Auth | 1/1/2025 ALL |
| J0139 | Injection, adalimumab, 1 mg [hcpcs.codes], [aapc.com] | ADD | Prior Auth | 4/1/2025 ALL |
| J0180 | Injection, adenosine diagnostic agent, per mg (verify current descriptor) | ADD | Prior Auth | 1/1/2025 ALL |
| J0458 | Emblaveo | REMOVE | Prior Auth | 10/16/2025 ALL |
| J0490 | Injection, anti-inflammatory biologic agent, per 1 mg (verify current descriptor) | ADD | Prior Auth | 11/1/2025 ALL |
| J0491 | Injection, anifrolumab-fnia, 1 mg | ADD | Prior Auth | 11/1/2025 ALL |
| J0614 | Grafapex | REMOVE | Prior Auth | 9/18/2025 ALL |
| J0666 | Bupivacaine and meloxicam extended-release solution, per mg | ADD | Prior Auth | 11/1/2025 ALL |
| J0681 | Zevtera | REMOVE | Prior Auth | 10/16/2025 ALL |
| J0870 | Rytelo | REMOVE | Prior Auth | 3/20/2025 ALL |
| J1072 | Azmiro | ADD | Prior Auth | 6/19/2025 ALL |
| J1299 | Injection, complement inhibitor biologic, 1 mg (verify current descriptor) | ADD | Prior Auth | 1/1/2025 ALL |
| J1307 | Injection, ravulizumab-cwvz, 10 mg | ADD | Prior Auth | 4/1/2025 ALL |
| J1307 | Piasky | ADD | Prior Auth | 3/20/2025 ALL |
| J1326 | Injection, tezepelumab-ekko, 1 mg | ADD | Prior Auth | 1/1/2025 ALL |
| J1326 | Vyloy | ADD | Prior Auth | 6/19/2025 ALL |
| J1414 | Injection, fitusiran, 1 mg (verify current descriptor) | ADD | Prior Auth | 7/1/2025 ALL |
| J1434 | Focinvez | ADD | Prior Auth | 1/16/2025 ALL |
| J1552 | Injection, immune globulin (SCIG), per 100 mg | ADD | Prior Auth | 1/1/2025 ALL |
| J1749 | Aurlumyn | REMOVE | Prior Auth | 6/19/2025 ALL |
| J2350 | Injection, ocrelizumab, 1 mg | ADD | Prior Auth | 1/1/2025 ALL |
| J2351 | Injection, ocrelizumab-hyaluronidase, 1 mg | ADD | Prior Auth | 1/1/2025 ALL |
| J2507 | KRYSTEXXA INJ 8MG/50ML | ADD | Prior Auth | 9/26/2025 ALL |
| J2508 | Injection, pegfilgrastim biosimilar, 0.5 mg (verify product-specific descriptor) | ADD | Prior Auth | 1/1/2025 ALL |
| J2802 | Injection, repository corticotropin, 1 unit | ADD | Prior Auth | 1/1/2025 ALL |
| J3285 | REMODULIN SOL 400MG | ADD | Prior Auth | 8/21/2025 ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| J3389 | Zevaskyn | ADD | Prior Auth | 9/18/2025 | ALL |
|---|---|---|---|---|---|
| J3391 | Injection, inclisiran sodium, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| J3392 | Injection, vutrisiran, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| J3402 | Injection, mirikizumab-mrkz, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| J3403 | Injection, tofersen, 1 mg | ADD | Prior Auth | 7/17/2025 | ALL |
| J3490 | Rapiblyk | REMOVE | Prior Auth | 9/18/2025 | ALL |
| J3590 | Kebilidi | ADD | Prior Auth | 7/17/2025 | ALL |
| J7173 | Injection, von Willebrand factor complex (recombinant), 1 IU | ADD | Prior Auth | 10/1/2025 | ALL |
| J7174 | Injection, emicizumab-kxwh, 0.5 mg | ADD | Prior Auth | 10/1/2025 | ALL |
| J7330 | Autologous cultured chondrocytes, implantation | ADD | Prior Auth | 10/1/2025 | ALL |
| J9011 | Injection, amivantamab-vmjw, 2 mg | ADD | Prior Auth | 7/17/2025 | ALL |
| J9024 | Injection, dostarlimab-gxly, 10 mg | ADD | Prior Auth | 1/16/2025 | ALL |
| J9026 | Injection, mosunetuzumab-axgb, 1 mg | ADD | Prior Auth | 1/16/2025 | ALL |
| J9028 | Injection, epcoritamab-bysp, 0.16 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| J9037 | Injection, tebentafusp-tebn, 1 mcg | REMOVE | Prior Auth | 1/1/2025 | ALL |
| J9038 | Injection, belzutifan, 1 mg | ADD | Prior Auth | 7/15/2024 | ALL |
| J9054 | Injection, brexucabtagene autoleucel, per therapeutic dose | ADD | Prior Auth | 4/1/2025 | ALL |
| J9076 | Injection, tisagenlecleucel, per therapeutic dose | ADD | Prior Auth | 1/1/2025 | ALL |
| J9161 | Injection, melphalan flufenamide, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| J9174 | Injection, mirvetuximab soravtansine-gynx, 1 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| J9256 | Imaavy | ADD | Prior Auth | 10/16/2025 | ALL |
| J9275 | Injection, lifileucel, per therapeutic dose | ADD | Prior Auth | 7/1/2025 | ALL |
| J9276 | Injection, toripalimab-tpzi, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| J9282 | Zusduri | ADD | Prior Auth | 11/20/2025 | ALL |
| J9289 | Injection, tarlatamab-dlle, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| J9292 | Injection, nemolizumab-ilto, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| J9292 | Pemetrexed (Avyxa) | ADD | Prior Auth | 1/1/2025 | ALL |
| J9326 | Emrelis | ADD | Prior Auth | 10/16/2025 | ALL |
| J9329 | Tevimbra | ADD | Prior Auth | 5/15/2025 | ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| J9340 | Injection, retifanlimab-dlwr, 1 mg | REMOVE | Prior Auth | 1/1/2025 | ALL |
|---|---|---|---|---|---|
| J9341 | Injection, serplulimab, 1 mg | ADD | Prior Auth | 7/15/2024 | ALL |
| J9342 | Injection, penpulimab, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| J9361 | Ryzneuta | ADD | Prior Auth | 10/16/2025 | ALL |
| J9382 | Injection, zanidatamab, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| L1005 | Tension-based scoliosis orthosis and accessories | ADD | Prior Auth | 7/1/2025 | ALL |
| L5657 | Addition to lower extremity prosthesis, socket insert | ADD | Prior Auth | 4/1/2025 | ALL |
| L5827 | Addition to lower extremity prosthesis, endoskeletal knee-shin system component | ADD | Prior Auth | 10/1/2025 | ALL |
| L6028 | Partial foot prosthesis, transmetatarsal, molded socket | ADD | Prior Auth | 4/1/2025 | ALL |
| L6029 | Partial foot prosthesis, transmetatarsal, molded socket, ankle height | ADD | Prior Auth | 4/1/2025 | ALL |
| L6030 | Foot prosthesis, Syme's amputation, molded socket | ADD | Prior Auth | 4/1/2025 | ALL |
| L6031 | Foot prosthesis, Syme's amputation, flexible inner socket | ADD | Prior Auth | 4/1/2025 | ALL |
| L6032 | Foot prosthesis, Syme's amputation, external keel | ADD | Prior Auth | 4/1/2025 | ALL |
| L6033 | Foot prosthesis, Syme's amputation, with integrated ankle | ADD | Prior Auth | 4/1/2025 | ALL |
| L6034 | Foot prosthesis, Chopart amputation, molded socket | ADD | Prior Auth | 4/1/2025 | ALL |
| L6035 | Foot prosthesis, Chopart amputation, ankle-foot system | ADD | Prior Auth | 10/1/2025 | ALL |
| L6036 | Foot prosthesis, Lisfranc amputation, molded socket | ADD | Prior Auth | 10/1/2025 | ALL |
| L6038 | Foot prosthesis, transmetatarsal or midfoot, custom fabricated | ADD | Prior Auth | 10/1/2025 | ALL |
| L6039 | Addition to lower extremity prosthesis, custom toe filler | ADD | Prior Auth | 10/1/2025 | ALL |
| L6700 | Terminal device, partial hand prosthesis | ADD | Prior Auth | 10/1/2025 | ALL |
| L7406 | Addition to upper extremity prosthesis, electronic elbow feature | ADD | Prior Auth | 4/1/2025 | ALL |
| NA | Tyenne | ADD | Prior Auth | 1/16/2025 | ALL |
| NA | Tofidence | ADD | Prior Auth | 1/16/2025 | ALL |
| NA | Ojemda tablet | REMOVE | Prior Auth | 1/16/2025 | ALL |
| NA | Ojemda suspension | REMOVE | Prior Auth | 1/16/2025 | ALL |
| NA | Libervant | REMOVE | Prior Auth | 1/16/2025 | ALL |
| NA | Xolremdi | ADD | Prior Auth | 1/16/2025 | ALL |
| NA | Duvyzat | ADD | Prior Auth | 1/16/2025 | ALL |
| NA | Iqirvo | ADD | Prior Auth | 1/16/2025 | ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| NA | Myhibbin | ADD | Prior Auth | 1/16/2025 | ALL |
|---|---|---|---|---|---|
| NA | Nemluvio | ADD | Prior Auth | 3/20/2025 | ALL |
| NA | Ohtuvayre | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Sofdra | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Zoryve 0.15% cream | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Vafseo | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Vigafyde | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Voranigo | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Crexont | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Neffy | REMOVE | Prior Auth | 3/20/2025 | ALL |
| NA | Livdelzi | ADD | Prior Auth | 3/20/2025 | ALL |
| NA | Onyda XR | ADD | Prior Auth | 5/15/2025 | ALL |
| NA | Lazcluze | REMOVE | Prior Auth | 5/15/2025 | ALL |
| NA | Tryvio | REMOVE | Prior Auth | 5/15/2025 | ALL |
| NA | Yorvipath | ADD | Prior Auth | 5/15/2025 | ALL |
| NA | Lodoco | REMOVE | Prior Auth | 5/15/2025 | ALL |
| NA | Femlyv | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Ebglyss | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Miplyffa | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Aqneursa | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Cobenfy | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Vyalev | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Itovebi | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Hympavzi | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Opipza | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Emrosi | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Revuforj | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Danziten | REMOVE | Prior Auth | 6/19/2025 | ALL |
| NA | Nypozi | ADD | Prior Auth | 6/19/2025 | ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| NA | Attruby | ADD | Prior Auth | 6/19/2025 | ALL |
|---|---|---|---|---|---|
| NA | Imkeldi | REMOVE | Prior Auth | 7/17/2025 | ALL |
| NA | Qlosi | REMOVE | Prior Auth | 7/17/2025 | ALL |
| NA | Crenessity capsules | ADD | Prior Auth | 7/17/2025 | ALL |
| NA | Crenessity oral solution | ADD | Prior Auth | 7/17/2025 | ALL |
| NA | Tryngolza | ADD | Prior Auth | 7/17/2025 | ALL |
| NA | Alyftrek | ADD | Prior Auth | 6/19/2025 | ALL |
| NA | Alhemo | ADD | Prior Auth | 7/17/2025 | ALL |
| NA | Journavx | REMOVE | Prior Auth | 7/17/2025 | ALL |
| NA | Gomekli capsule | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Gomekli oral suspension | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Onapgo | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Xromi | REMOVE | Prior Auth | 9/18/2025 | ALL |
| NA | Zunveyl | REMOVE | Prior Auth | 9/18/2025 | ALL |
| NA | Romvimza | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Alhemo | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Raldesy | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Inzirqo | REMOVE | Prior Auth | 9/18/2025 | ALL |
| NA | Revuforj | REMOVE | Prior Auth | 9/18/2025 | ALL |
| NA | Vykat XR | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Vanrafia | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Tezruly | REMOVE | Prior Auth | 9/18/2025 | ALL |
| NA | Qfitlia | ADD | Prior Auth | 9/18/2025 | ALL |
| NA | Symbravo | ADD | Prior Auth | 10/16/2025 | ALL |
| NA | AVMAPKI | REMOVE | Prior Auth | 10/16/2025 | ALL |
| NA | Yutrepia | ADD | Prior Auth | 10/16/2025 | ALL |
| NA | KHINDIVI | REMOVE | Prior Auth | 10/16/2025 | ALL |
| NA | Merilog | ADD | Prior Auth | 11/20/2025 | ALL |
| NA | Leqselvi | ADD | Prior Auth | 11/20/2025 | ALL |
MVP Health Care Responses Vermont Prior Authorization Attestation Form (2026)
| NA | Ensacove | REMOVE | Prior Auth | 11/20/2025 | ALL |
|---|---|---|---|---|---|
| NA | Arbli | REMOVE | Prior Auth | 11/20/2025 | ALL |
| NA | Zelsuvmi | REMOVE | Prior Auth | 11/20/2025 | ALL |
| NA | Ibtrozi | REMOVE | Prior Auth | 11/20/2025 | ALL |
| NA | Averi | REMOVE | Prior Auth | 11/20/2025 | ALL |
| NA | Andembry | ADD | Prior Auth | 11/20/2025 | ALL |
| NA | Leqembi SQ | ADD | Prior Auth | 10/16/2025 | ALL |
| NA | XPOVIO PAK 40MG | ADD | Prior Auth | 3/14/2025 | ALL |
| NA | TREMFYA CROH INJ 200/2ML | ADD | Prior Auth | 3/28/2025 | ALL |
| NA | VYVGART INJ HYTRULO | ADD | Prior Auth | 4/18/2025 | ALL |
| NA | LIVMARLI TAB 10MG | ADD | Prior Auth | 5/9/2025 | ALL |
| NA | LIVMARLI TAB 15MG | ADD | Prior Auth | 5/9/2025 | ALL |
| NA | LIVMARLI TAB 20MG | ADD | Prior Auth | 5/9/2025 | ALL |
| NA | LIVMARLI TAB 30MG | ADD | Prior Auth | 5/9/2025 | ALL |
| NA | LEQEMBI IQLK INJ 360/1.8 | ADD | Prior Auth | 9/5/2025 | ALL |
| NA | EBGLYSS INJ 250/2ML | ADD | Prior Auth | 11/1/2025 | ALL |
| NA | EBGLYSS INJ 250/2ML | ADD | Prior Auth | 11/1/2025 | ALL |
| NA | DOPTELET SPR CAP 10MG | ADD | Prior Auth | 9/26/2025 | ALL |
| NA | OTEZLA/XR TAB 28 DAY | ADD | Prior Auth | 9/26/2025 | ALL |
| NA | OTEZLA XR TAB 75MG | ADD | Prior Auth | 9/26/2025 | ALL |
| NA | KOSELUGO CAP 5MG | ADD | Prior Auth | 10/10/2025 | ALL |
| NA | KOSELUGO CAP 7.5MG | ADD | Prior Auth | 10/10/2025 | ALL |
| NA | GLYCEROL PHENYLBUTYRATE LIQUID 1.1 GM/ML | ADD | Prior Auth | 10/17/2025 | ALL |
| NA | GABAPENTIN (ONCE-DAILY) TAB 450 MG | ADD | Prior Auth | 12/3/2025 | ALL |
| NA | GABAPENTIN (ONCE-DAILY) TAB 750 MG | ADD | Prior Auth | 12/3/2025 | ALL |
| NA | GABAPENTIN (ONCE-DAILY) TAB 900 MG | ADD | Prior Auth | 12/3/2025 | ALL |
| NA | TYVASO DPI POW 80MCG | ADD | Prior Auth | 11/14/2025 | ALL |
| NA | TYVASO DPI POW MAIN KIT | ADD | Prior Auth | 11/21/2025 | ALL |
| NA | TYVASO DPI POW MAIN KIT | ADD | Prior Auth | 11/21/2025 | ALL |
MVP Health Care Responses
Vermont Prior Authorization Attestation Form (2026)
| NA | XPOVIO PAK 80MG | ADD | Prior Auth | 12/26/2025 | ALL |
|---|---|---|---|---|---|
| Q2058 | Allogeneic cultured chondrocytes, per implantation | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5098 | Injection, aflibercept biosimilar, 2 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| Q5099 | Injection, aflibercept-mrbb biosimilar, 2 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| Q5100 | Injection, filgrastim biosimilar, 1 microgram | ADD | Prior Auth | 7/1/2025 | ALL |
| Q5133 | Tofidence | ADD | Prior Auth | 1/16/2025 | ALL |
| Q5135 | Tyenne | ADD | Prior Auth | 1/16/2025 | ALL |
| Q5139 | Injection, tocilizumab-aazg, biosimilar, 1 mg | ADD | Prior Auth | 7/1/2025 | ALL |
| Q5140 | Injection, ustekinumab biosimilar, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5141 | Injection, ustekinumab-auub, biosimilar, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5142 | Injection, ustekinumab-kfce, biosimilar, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5143 | Injection, denosumab biosimilar, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5144 | Injection, denosumab biosimilar, 1 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5145 | Injection, pertuzumab biosimilar, 10 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5146 | Injection, pertuzumab-trastuzumab biosimilar combination, 10 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5147 | Pavblu | REMOVE | Prior Auth | 1/16/2025 | ALL |
| Q5148 | Injection, bevacizumab biosimilar, 10 mg | ADD | Prior Auth | 1/1/2025 | ALL |
| Q5149 | Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5150 | Injection, aflibercept-yszy, biosimilar, 2 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5151 | Injection, aflibercept-mrbb, biosimilar, 2 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5152 | Injection, trastuzumab biosimilar, 10 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5154 | Injection, pembrolizumab biosimilar, 1 mg | ADD | Prior Auth | 4/1/2025 | ALL |
| Q5156 | Injection, nivolumab biosimilar, 1 mg | ADD | Prior Auth | 10/1/2025 | ALL |
| Q5157 | Injection, ustekinumab biosimilar, 1 mg | ADD | Prior Auth | 10/1/2025 | ALL |
| Q5157 | Stoboclo/Osenvelt | ADD | Prior Auth | 10/1/2025 | ALL |
| Q5158 | Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mg | ADD | Prior Auth | 10/1/2025 | ALL |
| Q5159 | Injection, denosumab-dssb (Ospomyv/Xbryk), biosimilar, 1 mg [hcpcs.codes] | ADD | Prior Auth | 10/1/2025 | ALL |
| Q9996 | Injection, investigational biologic agent, per HCPCS descriptor | ADD | Prior Auth | 10/1/2025 | ALL |
| Q9997 | Injection, investigational biologic agent, per HCPCS descriptor | ADD | Prior Auth | 1/1/2025 | ALL |
MVP Health Care Responses
Vermont Prior Authorization Attestation Form (2026)
| Prior Auth | |||||
|---|---|---|---|---|---|
| Q9998 | Injection, investigational biologic agent, per HCPCS descriptor | ADD | Prior Auth | 1/1/2025 | ALL |
| Q9999 | Not otherwise classified antineoplastic drugs | ADD | Prior Auth | 1/1/2025 | ALL |
| S2112 | Arthroscopic cartilage implantation, including harvesting and implantation | ADD | Prior Auth | 4/1/2025 | ALL |
| S9124 | Nursing care, in the home, by registered nurse, per hour | ADD | Prior Auth | 10/1/2025 | ALL |
| T1000 | Private duty/independent nursing service, licensed nurse, per 15 minutes | ADD | Prior Auth | 4/1/2025 | ALL |
3. What are the ten most requested PAs for both medical PAs and prescription drug PAs (20 total) during the preceding plan year? For each of the 20 PAs, please provide the number of PAs requested and approval rate for each PA (PAs in this list may overlap with eliminated PAs identified in question 2).
MVP Response:
The ten (10) most requested PAs for medical services are as follows:
| Procedure Code and Description | Approved | % Approved | Denied | % Denied | Total Auths |
|---|---|---|---|---|---|
| A4238, A4239, E2103: CGM monitors/supplies | 3696 | 78% | 1045 | 22% | 4741 |
| 93656, 93657: A-fib ablation | 705 | 96% | 26 | 4% | 731 |
| E1399: Misc DME | 155 | 33% | 314 | 67% | 469 |
| K0108: Misc wheelchair equipment | 301 | 83% | 60 | 17% | 361 |
| 58970, 58974, 89250-89353: In-vitro Fertilization | 419 | 57% | 312 | 43% | 731 |
| 19318: Breast reduction | 132 | 50% | 132 | 50% | 264 |
| E0784: Insulin infusion pump | 229 | 93% | 16 | 7% | 245 |
| E2402: Neg pressure wound pumps | 219 | 96% | 10 | 4% | 229 |
| E0650-E0652: Pneumatic comp devices and appliances | 186 | 88% | 25 | 12% | 211 |
| 63650-63685, L8680: Spinal cord stimulators and trials | 225 | 97% | 8 | 3% | 233 |
The ten (10) most requested PAs for pharmacy services are as follows:
| Product Name | Approved | % Approved | Denied | % Denied | Total Auths |
|---|---|---|---|---|---|
| Zepbound | 754 | 71% | 302 | 29% | 1056 |
| Wegovy | 502 | 76% | 161 | 24% | 663 |
| Mounjaro | 175 | 75% | 58 | 25% | 233 |
| Ozempic (0.25 or 0.5 MG/D | 138 | 79% | 37 | 21% | 175 |
| Dupixent | 68 | 91% | 7 | 9% | 75 |
| Humira (2 Pen) | 65 | 98% | 1 | 2% | 66 |
| Ozempic (2 MG/DOSE) | 63 | 95% | 3 | 5% | 66 |
| Trulicity | 53 | 98% | 1 | 2% | 54 |
| TADALAFIL | 14 | 26% | 39 | 74% | 53 |
| Ozempic (1 MG/DOSE) | 43 | 90% | 5 | 10% | 48 |
4. What percentage of urgent and non-urgent PA requests are granted because processing time exceeded the statutory timeframes established under 18 V.S.A. § 9418b(g)(4)?
MVP Response: 6.5%
Is that number combining urgent and non-urgent categories? If possible, please submit this information broken out by urgent and non-urgent percentages.
MVP Response:
Urgent: 2.8%
Non-urgent: 3.7%
Note from RegAlert. AI assistants can read this document in full, and search 70,000+ more, through the RegAlert MCP connector (https://mcp.regalert.today/mcp). Free with an account. How to connect ChatGPT, Claude or Cursor.
- Obligation 7
- Permission 2
- Definition / condition 284
- Reporting template 12
- background, boilerplate
More like this from DFR
DFR published 8 documents in the last 30 days. We email you each new one the day it's published.
Source: Vermont Department of Financial Regulation — original document · Summary generated with machine assistance and reviewed before publication; the authoritative text is the regulator's original document. How RegAlert works
In RegAlert: added · updated