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 Last Modified
72HourSupply.pdfpdf May 01, 2012
Adagen.pdfpdf June 25, 2013
AdultAcne.pdfpdf June 25, 2013
AgeQuantityOverride.pdfpdf June 25, 2013
Aldurazyme.pdfpdf June 25, 2013
Aloxi.pdfpdf June 25, 2013
Amitiza.pdfpdf June 25, 2013
Ampyra.pdfpdf June 25, 2013
Androgens.pdfpdf November 21, 2013
Anti-Diabetic_-_DPP-4s.pdfpdf December 06, 2013
Anti-Diabetic_-_GLP-1s.pdfpdf December 06, 2013
Anti-Diabetic_-_SGLT-2s.pdfpdf January 21, 2014
Anti-Diabetic_-_TZDs.pdfpdf December 06, 2013
AntibioticsIVforNTM.pdfpdf June 25, 2013
AntiEmeticIVforNTM.pdfpdf June 25, 2013
Aralast.pdfpdf June 25, 2013
Aranesp.pdfpdf June 25, 2013
Arava.pdfpdf June 25, 2013
Arixtra.pdfpdf February 06, 2014
Avastin.pdfpdf August 01, 2013
BotulinumToxins.pdfpdf July 31, 2013
Brand_Name_Medication.pdfpdf June 25, 2013
ButalbitalProducts.pdfpdf January 30, 2014
Butrans.pdfpdf June 25, 2013
Cerezyme.pdfpdf June 25, 2013
Chantix.pdfpdf July 11, 2013
Cimzia_Crohns.pdfpdf June 25, 2013
Cimzia_RA_and_PA.pdfpdf October 01, 2013
Colcrys.pdfpdf June 25, 2013
Combunox.pdfpdf February 17, 2012
Cycloset.pdfpdf June 25, 2013
Cytogam.pdfpdf February 06, 2014
DepoProvera.pdfpdf February 06, 2014
DURBAppealRequest.pdfpdf June 25, 2013
Embeda.pdfpdf June 25, 2013
Emend.pdfpdf June 25, 2013
Emsam.pdfpdf June 25, 2013
Enbrel.pdfpdf June 25, 2013
Enbrel_JIA.pdfpdf June 25, 2013
Enbrel_Plaque_Psoriasis.pdfpdf June 25, 2013
EpinephrineNTM.pdfpdf June 25, 2013
Erythropoetins.pdfpdf February 06, 2014
Fabrazyme.pdfpdf February 06, 2014
Forteo.pdfpdf June 25, 2013
Gabapentin_ER.pdfpdf July 31, 2013
Gilenya.pdfpdf June 25, 2013
Growth_Hormone.pdfpdf June 25, 2013
Growth_Hormone_AIDS.pdfpdf June 25, 2013
Heparin_NTM.pdfpdf February 06, 2014
Hepsera.pdfpdf June 25, 2013
Humira.pdfpdf June 25, 2013
Humira_Crohns.pdfpdf June 25, 2013
Humira_JIA.pdfpdf August 01, 2013
Humira_Plaque_Psoriasis.pdfpdf August 01, 2013
Humira_Ulcerative_Colitis.pdfpdf July 03, 2013
Hydroxyprogesterone_Caproate.pdfpdf February 28, 2014
Increlex.pdfpdf February 06, 2014
InnohepNTM.pdfpdf February 06, 2014
Insulin_Pens.pdfpdf June 25, 2013
Istodax.pdfpdf March 04, 2014
Ketorolac.pdfpdf June 25, 2013
Kineret.pdfpdf June 25, 2013
Krystexxa.pdfpdf August 01, 2013
Lactulose.pdfpdf June 25, 2013
Lamisil.pdfpdf July 11, 2013
LowMolecularWeightHeparinsforNTM.pdfpdf July 31, 2013
Luxiq_Foam.pdfpdf June 25, 2013
Metabolic_Supplements.pdfpdf June 25, 2013
MSBiologicsforNTM.pdfpdf June 25, 2013
NeupogenNeulastaLeukine.pdfpdf February 06, 2014
Nexavar.pdfpdf February 06, 2014
Non-Preferred_Combo_&_Kit.pdfpdf November 14, 2013
Non-Preferred_Drug_Auth.pdfpdf November 14, 2013
Non-Sedating_Antihistamines.pdfpdf June 25, 2013
Nucynta.pdfpdf June 25, 2013
Nucynta_ER.pdfpdf June 25, 2013
Nuvigil.pdfpdf June 25, 2013
Olux_Foam.pdfpdf June 25, 2013
Omontys.pdfpdf June 25, 2013
Orencia.pdfpdf August 01, 2013
Oxandrin.pdfpdf November 21, 2013
Panretin.pdfpdf June 25, 2013
Pegasys&PegIntron.pdfpdf June 25, 2013
Pradaxa.pdfpdf September 25, 2013
Prolastin.pdfpdf June 25, 2013
Provigil.pdfpdf June 25, 2013
Qualaquin.pdfpdf June 25, 2013
Raptiva.pdfpdf June 25, 2013
Regranex.pdfpdf June 25, 2013
Relenza.pdfpdf June 25, 2013
Relistor.pdfpdf June 25, 2013
Remicade.pdfpdf August 01, 2013
Remicade_Crohns.pdfpdf August 01, 2013
Remicade_JIA.pdfpdf August 01, 2013
Remicade_Plaque_Psoriasis.pdfpdf August 01, 2013
Remicade_Ulcerative_Colitis.pdfpdf August 01, 2013
Restasis.pdfpdf June 25, 2013
Retin-A.pdfpdf June 25, 2013
Salagen.pdfpdf June 25, 2013
Samsca.pdfpdf June 25, 2013
Selzentry.pdfpdf June 25, 2013
Simponi.pdfpdf June 25, 2013
Simvastatin.pdfpdf June 25, 2013
Sirturo.pdfpdf August 28, 2013
Soliris.pdfpdf December 30, 2013
Somavert.pdfpdf February 06, 2014
Stimulants_Adults.pdfpdf November 14, 2013
Stimulants_Children.pdfpdf September 25, 2013
Suboxone_&_Zubsolv.pdfpdf November 15, 2013
Sutent.pdfpdf June 25, 2013
Symlin.pdfpdf June 25, 2013
Synagis.pdfpdf June 13, 2013
Tamiflu.pdfpdf October 23, 2013
Trizivir.pdfpdf June 25, 2013
Tykerb.pdfpdf June 25, 2013
Tysabri.pdfpdf August 01, 2013
Uloric.pdfpdf June 25, 2013
Vectibix.pdfpdf August 01, 2013
Victoza.pdfpdf June 25, 2013
Vivitrol.pdfpdf June 25, 2013
Vpriv.pdfpdf February 06, 2014
XanaxXR.pdfpdf June 25, 2013
Xarelto.pdfpdf June 25, 2013
Xibrom.pdfpdf June 25, 2013
Xifaxan.pdfpdf August 06, 2013
Xolair.pdfpdf August 01, 2013
Xolegel.pdfpdf June 25, 2013
Xyrem.pdfpdf June 25, 2013
Zavesca.pdfpdf June 25, 2013
Zemaira.pdfpdf June 25, 2013
Zenzedi.pdfpdf September 25, 2013
Ziana.pdfpdf June 25, 2013
ZoviraxOintment.pdfpdf June 25, 2013