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Prior Authorization Forms

In 2013, the Vermont legislature passed Act 171 that amended 18 V.S.A. § 9418b to include requirements for the development of a uniform prior authorization (PA) form to standardize prior authorization requests for prescription drugs, medical procedures (to include both physical and mental health conditions), and medical tests required by Vermont health insurers and Medicaid (Department of Health Access). 

The Department of Financial Regulation (DFR) was required to collaborate with the Department of Health Access (DVHA), the Vermont Medical Society (VMS), and health insurers in developing a “clear, uniform, and readily accessible” prior authorization form for use by all relevant Vermont providers. The uniform prior authorization form will be used for all types of medical treatment that requires prior authorization, including mental health and substance abuse. The uniform prior authorization form for medical service requests was finalized by September 1, 2013, as required. 

Based on stakeholder research and feedback regarding prior authorization of prescription drug, DFR determined that the extent of the operational and clinical differences among health plans for authorizing prescription drugs were too complex to be effectively transformed to a standardized form. Each health insurer and DVHA will continue to use their own prior authorization forms for pharmacy services.

Prior Authorizations: Acceptance and Access 

According to statute, each insurer must accept either the national standard transaction information for prior authorizations electronically via online portal or the uniform prior authorization form approved by DFR for requests for medical procedures (including mental health services) and medical tests when prior authorization is required beginning on or after March 1, 2014. Review the statute here.

The statute also requires that the Vermont Uniform Prior Authorization Form(s) be available on DFR’s website and the websites of each health insurer. Providers requesting prior authorization must send or fax a completed form to the member’s health plan in advance of the proposed services.

  • Please refer to information provided on each health plans’ website for submission instructions and contact information.
  • Use the below links to obtain a uniform medical or prescription drug prior authorization form from each insurer, including submission instructions and contact information.

In 2023, stakeholders including the Department of Financial Regulation, Department of Vermont Health Access, Blue Cross Blue Shield of Vermont, MVP Health Care and Cigna met to revise the form. The new form will be phased in by all payers starting January 1, 2024. Access the new form in Adobe Acrobat file format.

Questions? Contact DFR Assistant General Counsel Sebastian Arduengo by phone (802-828-4846) and email (




  • To request prior authorization or approval of an excluded medication, providers have the following options available:
    • Use CoverMyMeds (Member ID should include the last letter - usually V - followed by twelve numbers and the two-digit member number)
    • Call Vermont Blue Rx at (800) 313-7879


Medical PA Form (Using the secure provider portal.)

Pharmacy PA Form: 

  1. Pharmacy Prior Authorization Forms (using the secure provider portal go to Resources>Pharmacy Resources>Pharmacy Prior Authorization Forms.)
  2. To submit an online prior authorization request for prescription drugs covered under the Cigna pharmacy benefit or the Cigna medical benefit at: 


Medicaid (Dept. of Vermont Health Access)

Prior Authorization Forms