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
Aldurazyme.pdfpdf
Aloxi.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
buprenorphine.pdfpdf
ButalbitalProducts.pdfpdf
Butrans.pdfpdf
Cerezyme.pdfpdf
Chantix.pdfpdf
Cimzia Crohns.pdfpdf
Cimzia RA & PA.pdfpdf
Colchicine.pdfpdf
Combunox.pdfpdf
Cosentyx PP, PA & AS.pdfpdf
Cycloset.pdfpdf
Cytogam.pdfpdf
DepoProvera.pdfpdf
DURBAppealRequest.pdfpdf
Embeda.pdfpdf
Emend.pdfpdf
Emsam.pdfpdf
Enbrel all indications.pdfpdf
Entresto.pdfpdf
Entresto_draft.pdfpdf
Entyvio Crohns.pdfpdf
Entyvio UC.pdfpdf
EpinephrineNTM.pdfpdf
Erythropoetins.pdfpdf
Fabrazyme.pdfpdf
Forteo.pdfpdf
GabapentinER.pdfpdf
Grastek.pdfpdf
GrowthHormone.pdfpdf
GrowthHormoneAIDS.pdfpdf
HeparinNTM.pdfpdf
Hepatitis C.pdfpdf
Hepsera.pdfpdf
Humira Crohns.pdfpdf
Humira JIA, RA, PA, AS & PP.pdfpdf
Humira UC.pdfpdf
Hyaluronic Acid.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Increlex.pdfpdf
Innohep.pdfpdf
InsulinPens.pdfpdf
Istodax.pdfpdf
Kalydeco.pdfpdf
Ketorolac.pdfpdf
Kineret CAPS.pdfpdf
Kineret RA.pdfpdf
Krystexxa.pdfpdf
Lactulose.pdfpdf
Lidocaine.pdfpdf
Lovenox_and_Fragmin_for_NTM.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
MetabolicSupplements.pdfpdf
Movantik.pdfpdf
MS Oral Drugs.pdfpdf
MSBiologicsNTM.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
Nexavar.pdfpdf
NonPreferredCombo&Kit.pdfpdf
NonPreferredDrugAuth.pdfpdf
Nucynta.pdfpdf
NucyntaER.pdfpdf
Nuvigil.pdfpdf
Oralair.pdfpdf
Orencia all indications.pdfpdf
Orkambi.pdfpdf
Otezla PP.pdfpdf
Oxandrin.pdfpdf
Panretin.pdfpdf
PCSK9 inhibitors.pdfpdf
Physician Administered Review Request Form.pdfpdf
PPI.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
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
Vivitrol.pdfpdf
Vpriv.pdfpdf
XanaxXR.pdfpdf
Xeljanz RA.pdfpdf
Xibrom.pdfpdf
Xifaxan.pdfpdf
Xolair.pdfpdf
Xyrem PA modified criteria DRAFT.pdfpdf
Xyrem.pdfpdf
Zavesca.pdfpdf
Zenzedi.pdfpdf