Vermont Medicaid uses this general form for prescription drug prior authorization when no drug-specific form applies, and Optum administers the pharmacy benefit for the Department of Vermont Health Access. A prescriber meets it when a member's medication requires prior authorization. The form also covers drugs billed under the medical benefit, which need a HCPCS J-code and the administering provider's details.
The prescriber completes the whole two-page form, signs and dates it. It covers the prescribing physician, beneficiary, pharmacy and, for medical benefit drugs, the administering provider or facility.
Download the current version from the source each time; forms change without notice.
General Prior Authorization Request Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. A section must be completed for medical benefit requests, giving the HCPCS J-code or other code and the administering provider or facility's name, NPI and Medicaid ID. The rest of the form, including the drug, diagnosis and prior treatments, is the same for pharmacy and medical benefit requests.
The diagnosis for the medication, history of conditions, allergies or other information that makes the drug necessary, whether another provider has seen the patient for the condition and their specialty, preferred drugs tried and failed, and relevant labs or procedures with findings and dates. The current version was updated March 2025.