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
Adagen (pegademase bovine).pdfpdf
Adcetris (brantuximab vedotin).pdfpdf
Aldurazyme (laronidase).pdfpdf
Aloxi (palonostron hcl).pdfpdf
Androgens.pdfpdf
Aralast (alpha1-proteinase inhibitor (human) liquid).pdfpdf
Avastin (bevacizumab).pdfpdf
Botulinum Toxins.pdfpdf
Braftovi (encorafenib)-Mektovi (binimetinib).pdfpdf
Brand Name.pdfpdf
Buprenorphine_Naloxone.pdfpdf
Butalbital Products.pdfpdf
Cerezyme (imiglucerase).pdfpdf
Combo Product.pdfpdf
Crysvita (burosumab-twza).pdfpdf
Cycloset (bromocriptine).pdfpdf
Cystic Fibrosis Gene Therapies.pdfpdf
Cytogam (cytomegalovirus immune globulin).pdfpdf
Doptelet (avatrombopag).pdfpdf
Dosing Kit.pdfpdf
Dupixent.pdfpdf
Emend (aprepitant).pdfpdf
Emflaza (deflazacort).pdfpdf
Entresto (sacubitril-valsartan).pdfpdf
Exondys 51 (eteplirsen).pdfpdf
Fabrazyme (agalsidase beta).pdfpdf
Fasenra (benralizumab).pdfpdf
Forteo (teriparatide).pdfpdf
Grastek Immunotherapy.pdfpdf
Growth Hormone AIDS.pdfpdf
Growth Hormone.pdfpdf
Hemlibra (emicizumab).pdfpdf
Hemophilia Additional Nursing Visits.pdfpdf
Hepatitis C.pdfpdf
Hyaluronic Acid.pdfpdf
Hydroxyprogesterone Caproate.pdfpdf
Ilumya (tildrakizumab).pdfpdf
Increlex (mecasermin).pdfpdf
Istodax (romidepsin).pdfpdf
Jynarque (tolvaptan).pdfpdf
Krystexxa (pegloticase).pdfpdf
Kymriah (tisagenlecleucel).pdfpdf
Lidocaine (Topical).pdfpdf
Long acting opiates.pdfpdf
Lucemyra (lofexidine).pdfpdf
Luxturna (voretigene).pdfpdf
Mepsevii (vestronidase alfa-vjbk).pdfpdf
Methadone.pdfpdf
Naltrexone Quantity Override.pdfpdf
Neudexta (dextromethorphan-quinidine).pdfpdf
New to Market Drugs.pdfpdf
Nexavar (sorafenib).pdfpdf
Nocdurna (desmopressin acetate) Sublingual PA.pdfpdf
Non-preferred PA.pdfpdf
Nuvigil (armodafinil)-Provigil (modafinil).pdfpdf
Ocrevus (ocrelizumab).pdfpdf
Off Label use of FDA approved drugs.pdfpdf
Onpattro (patisiran) IV, Tegsedi (inotersen).pdfpdf
Oralair.pdfpdf
Orilissa (elagolix).pdfpdf
Oxandrin (oxandrolone).pdfpdf
PAH.pdfpdf
PAMORAs.pdfpdf
Panretin (Alitretinoin).pdfpdf
PCSK9 inhibitors.pdfpdf
Physician Administered Review Request Form.pdfpdf
PPI.pdfpdf
Prolastin-Zemaira.pdfpdf
Qualaquin (quinine).pdfpdf
Quantity Override Request.pdfpdf
Ragwitek.pdfpdf
Ravicti (glycerol phenylbutyrate), Buphenyl (Sodium Phenylbutyrate).pdfpdf
Regranex (becaplermin).pdfpdf
Remicade, Inflectra (infliximab).pdfpdf
Restasis (Cyclosporine Ophthalmic Emulsion).pdfpdf
Retinoids (Topical).pdfpdf
Samsca (tolvaptan).pdfpdf
Simvastatin.pdfpdf
Sirturo (bedaquiline).pdfpdf
Soliris (eculizumab).pdfpdf
Somavert (pegvisomant).pdfpdf
Spinraza (nusinersen).pdfpdf
Step Therapy.pdfpdf
Sutent (sunitinib).pdfpdf
Symlin (pramlintide).pdfpdf
Synagis (palivizumab).pdfpdf
Topical Immunomodulators.pdfpdf
Tykerb (lapatinib).pdfpdf
Vectibix (panitumumab).pdfpdf
Vivitrol (naltrexone er)-Sublocade (buprenorphine er).pdfpdf
Vpriv (velaglucerase alfa).pdfpdf
Xifaxan (rifaximin).pdfpdf
Xolair (omalizumab).pdfpdf
Xyrem (sodium oxybate).pdfpdf
Zavesca (miglustat).pdfpdf