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
Arixtra.pdfpdf
AntiEmeticIVforNTM.pdfpdf
AntibioticsIVforNTM.pdfpdf
Adagen.pdfpdf
BrandNameMedication.pdfpdf
Aldurazyme.pdfpdf
ButalbitalProducts.pdfpdf
Butrans.pdfpdf
Aralast.pdfpdf
Cerezyme.pdfpdf
AdultAcne.pdfpdf
Ampyra.pdfpdf
72HourSupply.pdfpdf
MetabolicSupplements.pdfpdf
Ketorolac.pdfpdf
Innohep.pdfpdf
Combunox.pdfpdf
InsulinPens.pdfpdf
GrowthHormone.pdfpdf
DepoProvera.pdfpdf
HeparinNTM.pdfpdf
Nexavar.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
EpinephrineNTM.pdfpdf
Cycloset.pdfpdf
Krystexxa.pdfpdf
Cytogam.pdfpdf
Increlex.pdfpdf
GrowthHormoneAIDS.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Emsam.pdfpdf
Istodax.pdfpdf
MSBiologicsNTM.pdfpdf
Fabrazyme.pdfpdf
Emend.pdfpdf
Embeda.pdfpdf
Provigil.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Simvastatin.pdfpdf
Nuvigil.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
Tykerb.pdfpdf
Relistor.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Retin-A.pdfpdf
Sutent.pdfpdf
Regranex.pdfpdf
Somavert.pdfpdf
Selzentry.pdfpdf
Samsca.pdfpdf
Salagen.pdfpdf
Vectibix.pdfpdf
Xifaxan.pdfpdf
Zavesca.pdfpdf
Uloric.pdfpdf
XanaxXR.pdfpdf
Xibrom.pdfpdf
Vpriv.pdfpdf
Xolair.pdfpdf
Oxandrin.pdfpdf
Colchicine.pdfpdf
Topical Immunomodulators.pdfpdf
Synagis.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Physician Administered Review Request Form.pdfpdf
Aloxi.pdfpdf
Oralair.pdfpdf
Restasis.pdfpdf
Avastin.pdfpdf
Grastek.pdfpdf
Hyaluronic Acid.pdfpdf
Ragwitek.pdfpdf
Kalydeco.pdfpdf
Orkambi.pdfpdf
Androgens.pdfpdf
Vivitrol.pdfpdf
Lidocaine.pdfpdf
PCSK9 inhibitors.pdfpdf
Botulinum Toxins.pdfpdf
buprenorphine.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Xyrem.pdfpdf
NonPreferredDrugAuth.pdfpdf
Movantik.pdfpdf
Hepatitis C.pdfpdf
Revatio PA.pdfpdf
Adcirca PA.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
PPI.pdfpdf
Entresto.pdfpdf