Prior Authorization

Listed below are all the PA forms you will need in order to request drugs that require prior authorization.

To submit a request via fax:

  • Select and print the proper form from the list below
  • Gather all of the requested documentation, including a letter of medical necessity if requested.
  • Fax the completed form to the Prior Authorization Team at (855) 828-4992.

To submit a request online:

  • Login into the Utah Pharmacy Provider Portal.
  • Navigate to criteria and gather all of the requested documentation, including a letter of medical necessity if requested.
  • Fill in required member and prescriber information.
  • Follow instruction in portal for documentation uploading or fax the completed documentation to the Prior Authorization Team at (855) 828-4992.

The documents are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.

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Name Type
72HourSupply.pdfpdf
Actemra all indications.pdfpdf
Adagen.pdfpdf
AdultAcne.pdfpdf
AgeQuantityOverride.pdfpdf
Aldurazyme.pdfpdf
Aloxi.pdfpdf
Amitiza.pdfpdf
Ampyra.pdfpdf
Androgens.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
AntibioticsIVforNTM.pdfpdf
AntiEmeticIVforNTM.pdfpdf
Aralast.pdfpdf
Aranesp.pdfpdf
Arava all indications.pdfpdf
Arixtra.pdfpdf
Avastin.pdfpdf
Botulinum Toxins.pdfpdf
BrandNameMedication.pdfpdf
ButalbitalProducts.pdfpdf
Butrans.pdfpdf
Cerezyme.pdfpdf
Chantix.pdfpdf
Cimzia Crohns.pdfpdf
Cimzia RA & PA.pdfpdf
Colchicine.pdfpdf
Combunox.pdfpdf
Cosentyx Plaque Psoriasis.pdfpdf
Cycloset.pdfpdf
Cymbalta quantity override.pdfpdf
Cytogam.pdfpdf
DepoProvera.pdfpdf
DURBAppealRequest.pdfpdf
Embeda.pdfpdf
Emend.pdfpdf
Emsam.pdfpdf
Enbrel all indications.pdfpdf
Entyvio Crohns.pdfpdf
Entyvio UC.pdfpdf
EpinephrineNTM.pdfpdf
Erythropoetins.pdfpdf
Fabrazyme.pdfpdf
Forteo.pdfpdf
GabapentinER.pdfpdf
Grastek.pdfpdf
GrowthHormone.pdfpdf
GrowthHormoneAIDS.pdfpdf
Harvoni.pdfpdf
HeparinNTM.pdfpdf
Hepsera.pdfpdf
Humira Crohns.pdfpdf
Humira JIA, RA, PA, AS & PP.pdfpdf
Humira UC.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Increlex.pdfpdf
Innohep.pdfpdf
InsulinPens.pdfpdf
Istodax.pdfpdf
Ketorolac.pdfpdf
Kineret CAPS.pdfpdf
Kineret RA.pdfpdf
Krystexxa.pdfpdf
Lactulose.pdfpdf
Lamisil.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
LuxiqFoam.pdfpdf
MetabolicSupplements.pdfpdf
MS Oral Drugs.pdfpdf
MSBiologicsNTM.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
Nexavar.pdfpdf
NonPreferredCombo&Kit.pdfpdf
NonPreferredDrugAuth.pdfpdf
Nucynta.pdfpdf
NucyntaER.pdfpdf
Nuvigil.pdfpdf
OluxFoam.pdfpdf
Olysio.pdfpdf
Orencia all indications.pdfpdf
Otezla PP.pdfpdf
Oxandrin.pdfpdf
Panretin.pdfpdf
Pegasys&PegIntron.pdfpdf
Physician Administered Review Request Form.pdfpdf
PPI.pdfpdf
Pradaxa.pdfpdf
Prolastin&Zemaira.pdfpdf
Provigil.pdfpdf
Qualaquin.pdfpdf
Ragwitek.pdfpdf
Raptiva.pdfpdf
Regranex.pdfpdf
Relistor.pdfpdf
Remicade Crohns.pdfpdf
Remicade PP.pdfpdf
Remicade RA, PA & AS.pdfpdf
Remicade UC.pdfpdf
Restasis.pdfpdf
Retin-A.pdfpdf
Rituxan NHL, CLL, GPA & MPA.pdfpdf
Rituxan RA.pdfpdf
Salagen.pdfpdf
Samsca.pdfpdf
Selzentry.pdfpdf
Simponi RA, PA & AS.pdfpdf
Simponi UC.pdfpdf
Simvastatin.pdfpdf
Sirturo.pdfpdf
Soliris.pdfpdf
Somavert.pdfpdf
Sovaldi.pdfpdf
Stelara PA.pdfpdf
Stelara PP.pdfpdf
StimulantsAdults.pdfpdf
StimulantsChildren.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Sutent.pdfpdf
Symlin.pdfpdf
Synagis.pdfpdf
Topical Immunomodulators.pdfpdf
Trizivir.pdfpdf
Tykerb.pdfpdf
Uloric.pdfpdf
Vectibix.pdfpdf
Viekira Pak.pdfpdf
Vivitrol.pdfpdf
Vpriv.pdfpdf
XanaxXR.pdfpdf
Xarelto.pdfpdf
Xeljanz RA.pdfpdf
Xibrom.pdfpdf
Xifaxan.pdfpdf
Xolair.pdfpdf
Xolegel.pdfpdf
Xyrem.pdfpdf
Zavesca.pdfpdf
Zenzedi.pdfpdf
Ziana.pdfpdf
ZoviraxOintment.pdfpdf