Vermont Medicaid

FAVORABLE FOR COVERAGE: PHARMACY BENEFIT
Gelmix and Purathick are favorable for coverage as over-the-counter (OTC) products with a prescription under the pharmacy benefit.
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REQUIREMENTS
–Prescription required
–Prior Authorization required (must include quantity, day supply, diagnosis; refer to the resources below for full PA requirements)

PRODUCT NDC CODES
-Gelmix Infant Thickener (125g Jar): 55764-0007-02
-Gelmix Infant Thickener (2.4g Sticks): 55764-0007-11
-Purathick Natural Thickener (125g Jar): 55764-0007-03
-Purathick Natural Thickener (2.4g Sticks): 55764-0007-09

RESOURCES/LINKS
Nutritionals Prior Authorization Form
Department of Vermont Health Access OTC Drug List