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
Adagen.pdfpdf
Adcirca PA.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
Arixtra.pdfpdf
Avastin.pdfpdf
Botulinum Toxins.pdfpdf
BrandNameMedication.pdfpdf
buprenorphine.pdfpdf
ButalbitalProducts.pdfpdf
Butrans.pdfpdf
Cerezyme.pdfpdf
Colchicine.pdfpdf
Combunox.pdfpdf
Cycloset.pdfpdf
Cytogam.pdfpdf
DepoProvera.pdfpdf
Embeda.pdfpdf
Emend.pdfpdf
Emsam.pdfpdf
Entresto.pdfpdf
EpinephrineNTM.pdfpdf
Erythropoetins.pdfpdf
Fabrazyme.pdfpdf
Forteo.pdfpdf
GabapentinER.pdfpdf
Grastek.pdfpdf
GrowthHormone.pdfpdf
GrowthHormoneAIDS.pdfpdf
HeparinNTM.pdfpdf
Hepatitis C.pdfpdf
Hepsera.pdfpdf
Hyaluronic Acid.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Increlex.pdfpdf
Innohep.pdfpdf
InsulinPens.pdfpdf
Istodax.pdfpdf
Kalydeco.pdfpdf
Ketorolac.pdfpdf
Krystexxa.pdfpdf
Lactulose.pdfpdf
Lidocaine.pdfpdf
Lovenox_and_Fragmin_for_NTM.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
MetabolicSupplements.pdfpdf
Movantik.pdfpdf
MSBiologicsNTM.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
Nexavar.pdfpdf
NonPreferredCombo&Kit.pdfpdf
NonPreferredDrugAuth.pdfpdf
Nuvigil.pdfpdf
Oralair.pdfpdf
Orkambi.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
Regranex.pdfpdf
Relistor.pdfpdf
Restasis.pdfpdf
Retin-A.pdfpdf
Revatio PA.pdfpdf
Salagen.pdfpdf
Samsca.pdfpdf
Selzentry.pdfpdf
Simvastatin.pdfpdf
Sirturo.pdfpdf
Soliris.pdfpdf
Somavert.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
Xibrom.pdfpdf
Xifaxan.pdfpdf
Xolair.pdfpdf
Xyrem.pdfpdf
Zavesca.pdfpdf