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
72 Hour Supply.pdfpdf
Adagen (pegademase bovine).pdfpdf
Adcirca (tadalafil).pdfpdf
Adult Acne.pdfpdf
Aldurazyme (laronidase).pdfpdf
Aloxi (palonostron hcl).pdfpdf
Ampyra (dalfampridine).pdfpdf
Androgens.pdfpdf
Aralast (alpha1-proteinase inhibitor (human) liquid).pdfpdf
Avastin (bevacizumab).pdfpdf
Botulinum Toxins.pdfpdf
Brand Name.pdfpdf
Buprenorphine_Naloxone.pdfpdf
Butalbital Products.pdfpdf
Butrans (buprenorphine).pdfpdf
Cerezyme (imiglucerase).pdfpdf
Colchicine.pdfpdf
Combo Product.pdfpdf
Cycloset (bromocriptine).pdfpdf
Cytogam (cytomegalovirus immune globulin).pdfpdf
Dosing Kit.pdfpdf
Dupixent.pdfpdf
Emend (aprepitant).pdfpdf
Emflaza (deflazacort).pdfpdf
Emsam (selegiline).pdfpdf
Entresto (sacubitril-valsartan).pdfpdf
Exondys 51 (eteplirsen).pdfpdf
Fabrazyme (agalsidase beta).pdfpdf
Faserna (benralizumab).pdfpdf
Forteo (teriparatide).pdfpdf
Gabapentin ER (Gralise or Horizant).pdfpdf
Grastek Immunotherapy.pdfpdf
Growth Hormone AIDS.pdfpdf
Growth Hormone.pdfpdf
Hepatitis C.pdfpdf
Hyaluronic Acid.pdfpdf
Hydroxyprogesterone Caproate.pdfpdf
Increlex (mecasermin).pdfpdf
Istodax (romidepsin).pdfpdf
Kalydeco (ivacaftor).pdfpdf
Ketorolac.pdfpdf
Krystexxa (pegloticase).pdfpdf
Kymriah (tisagenlecleucel).pdfpdf
Lidocaine (Topical).pdfpdf
Long acting opiates.pdfpdf
Methadone.pdfpdf
Naltrexone Quantity Override.pdfpdf
New to Market Drugs.pdfpdf
Nexavar (sorafenib).pdfpdf
Non-preferred PA.pdfpdf
Nuvigil (armodafinil).pdfpdf
Oralair.pdfpdf
ORKAMBI (lumacaftor-ivacaftor).pdfpdf
Oxandrin (oxandrolone).pdfpdf
PAMORAs.pdfpdf
Panretin (Alitretinoin).pdfpdf
PCSK9 inhibitors.pdfpdf
Physician Administered Review Request Form.pdfpdf
PPI.pdfpdf
Preferred Step Through.pdfpdf
Prolastin-Zemaira.pdfpdf
Provigil (modafinil).pdfpdf
Qualaquin (quinine).pdfpdf
Quantity Override Request.pdfpdf
Ragwitek.pdfpdf
Regranex (becaplermin).pdfpdf
Restasis (Cyclosporine Ophthalmic Emulsion).pdfpdf
Retin-A (tretinoin gel).pdfpdf
Revatio (Sildenafil).pdfpdf
Samsca (tolvaptan).pdfpdf
Selzentry (maraviroc).pdfpdf
Simvastatin.pdfpdf
Sirturo (bedaquiline).pdfpdf
Soliris (eculizumab).pdfpdf
Somavert (pegvisomant).pdfpdf
Sutent (sunitinib).pdfpdf
Symlin (pramlintide).pdfpdf
Synagis (palivizumab).pdfpdf
Topical Immunomodulators.pdfpdf
Tykerb (lapatinib).pdfpdf
Uloric (febuxostat).pdfpdf
Vectibix (panitumumab).pdfpdf
Vivitrol (naltrexone er)-Sublocade (buprenorphine er).pdfpdf
Vpriv (velaglucerase alfa).pdfpdf
Xibrom (bromfenac).pdfpdf
Xifaxan (rifaximin).pdfpdf
Xolair (omalizumab).pdfpdf
Xyrem (sodium oxybate).pdfpdf
Zavesca (miglustat).pdfpdf