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.
Navigating the file list:
- After opening a document or directory, use the Back button in your browser to navigate out of directories or to navigate away from a document.