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
ABILIFY MYCITE (aripiprazole tablets with sensor).pdfpdf
Adagen (pegademase bovine).pdfpdf
Adcetris (brantuximab vedotin).pdfpdf
Aldurazyme (laronidase).pdfpdf
Androgens.pdfpdf
Antiemetics.pdfpdf
Aralast (alpha1-proteinase inhibitor (human) liquid).pdfpdf
Avastin (bevacizumab).pdfpdf
Botulinum Toxins.pdfpdf
Braftovi (encorafenib)-Mektovi (binimetinib).pdfpdf
Buprenorphine-Buprenorphine Naloxone.pdfpdf
Car-T Cell Therapies.pdfpdf
CGRP Antagonists.pdfpdf
Crysvita (burosumab-twza).pdfpdf
Cystic Fibrosis Gene Therapies.pdfpdf
Doptelet (avatrombopag).pdfpdf
Dupixent (dupilumab).pdfpdf
Emflaza (deflazacort).pdfpdf
Entresto (sacubitril-valsartan).pdfpdf
Epidiolex (cannabidiol).pdfpdf
Exception to 3 month supply.pdfpdf
Exondys 51 (eteplirsen).pdfpdf
Fabrazyme (agalsidase beta).pdfpdf
Fasenra (benralizumab).pdfpdf
Fluocinolone acetonide intravitreal implant.pdfpdf
Forteo (teriparatide).pdfpdf
Growth Hormone AIDS.pdfpdf
Growth Hormone.pdfpdf
Hemlibra (emicizumab).pdfpdf
Hemophilia Additional Nursing Visits.pdfpdf
Hepatitis C.pdfpdf
Hetlioz (tasimelteon).pdfpdf
Hydroxyprogesterone Caproate.pdfpdf
Ilumya (tildrakizumab).pdfpdf
Krystexxa (pegloticase).pdfpdf
Lidocaine.pdfpdf
Lucemyra (lofexidine).pdfpdf
Luxturna (voretigene).pdfpdf
Mavenclad.pdfpdf
Medication Coverage Exception Request.pdfpdf
Mepsevii (vestronidase alfa-vjbk).pdfpdf
Methadone.pdfpdf
Mifeprex (mifepristone).pdfpdf
New to Market Drugs.pdfpdf
Nexavar (sorafenib).pdfpdf
Nocdurna (desmopressin acetate) Sublingual PA.pdfpdf
Nuedexta (dextromethorphan-quinidine).pdfpdf
Nuvigil (armodafinil)-Provigil (modafinil)-Sunosi (solriamfetol).pdfpdf
Ocrevus (ocrelizumab).pdfpdf
Onpattro (patisiran) IV, Tegsedi (inotersen).pdfpdf
Opioid and Opioid Benzodiazepine Combination.pdfpdf
Oralair.pdfpdf
Orilissa (elagolix).pdfpdf
Oxandrin (oxandrolone).pdfpdf
PAMORAs.pdfpdf
Panretin (Alitretinoin).pdfpdf
PCSK 9 Inhibitors.pdfpdf
Physician Administered Review Request Form.pdfpdf
Prolastin-Zemaira (alpha-1 proteinase inhibitor).pdfpdf
Pulmonary Arterial Hypertension.pdfpdf
Qbrexza (topical glycopyrronium).pdfpdf
Ragwitek.pdfpdf
Ravicti (glycerol phenylbutyrate), Buphenyl (Sodium Phenylbutyrate).pdfpdf
Restasis, Cequa (Ophthalmic Cyclosporine).pdfpdf
Siliq (brodalumab) and Tremfya (guselkumab).pdfpdf
Sirturo (bedaquiline).pdfpdf
Spinraza (nusinersen).pdfpdf
Spravato (esketamine).pdfpdf
Sutent (sunitinib).pdfpdf
Synagis (palivizumab).pdfpdf
Topical Immunomodulators.pdfpdf
Xifaxan (rifaximin).pdfpdf
Xolair (omalizumab).pdfpdf
Xyrem (sodium oxybate).pdfpdf
Zolgensma (onasemnogene abeparvovec xioi).pdfpdf
Zulresso (brexanolone).pdfpdf