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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 tasked to work in consultation with the Department of Health Access (DVHA), the Vermont Medical Society (VMS), and health insurers to develop 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 has 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.

According to statute, each insurer must accept either the national standard transaction information for prior authorizations electronically via online portal or accept 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) must 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.

Providers may obtain a uniform medical or prescription drug prior authorization form from each insurer, including submission instructions and contact information, by clicking on one of the links below:


Medical PA Form
Pharmacy PA Form


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: 

Medical PA Form
Pharmacy PA Form (Refer to the Pharmacy section titled “Prior Authorization Forms” for all applicable forms.)

Medicaid (Dept. of Vermont Health Access)

Prior Authorization Forms

For any questions regarding this information, please contact Sebastian Arduengo, Assistant General Counsel, at 802-828-4846or via email at