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.

Get Adobe Reader

Name Type
Aralast.pdfpdf
Cerezyme.pdfpdf
AdultAcne.pdfpdf
Androgens.pdfpdf
Ampyra.pdfpdf
72HourSupply.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
Arixtra.pdfpdf
AntiEmeticIVforNTM.pdfpdf
AntibioticsIVforNTM.pdfpdf
Adagen.pdfpdf
Avastin.pdfpdf
Aranesp.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
BrandNameMedication.pdfpdf
Aldurazyme.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Chantix.pdfpdf
Aloxi.pdfpdf
BotulinumToxins.pdfpdf
Amitiza.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
AgeQuantityOverride.pdfpdf
MetabolicSupplements.pdfpdf
Emsam.pdfpdf
Cytogam.pdfpdf
Increlex.pdfpdf
Innohep.pdfpdf
GrowthHormoneAIDS.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Istodax.pdfpdf
Nucynta.pdfpdf
MSBiologicsNTM.pdfpdf
Lactulose.pdfpdf
Fabrazyme.pdfpdf
Emend.pdfpdf
Embeda.pdfpdf
Ketorolac.pdfpdf
LuxiqFoam.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Combunox.pdfpdf
InsulinPens.pdfpdf
Lamisil.pdfpdf
GrowthHormone.pdfpdf
DepoProvera.pdfpdf
HeparinNTM.pdfpdf
Erythropoetins.pdfpdf
Nexavar.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Hepsera.pdfpdf
EpinephrineNTM.pdfpdf
Cycloset.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
DURBAppealRequest.pdfpdf
Krystexxa.pdfpdf
NonPreferredDrugAuth.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Selzentry.pdfpdf
Raptiva.pdfpdf
Omontys.pdfpdf
Samsca.pdfpdf
Trizivir.pdfpdf
StimulantsAdults.pdfpdf
Salagen.pdfpdf
Provigil.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Restasis.pdfpdf
Simvastatin.pdfpdf
RemicadeJIA.pdfpdf
Pegasys&PegIntron.pdfpdf
NucyntaER.pdfpdf
Pradaxa.pdfpdf
Nuvigil.pdfpdf
OluxFoam.pdfpdf
Tykerb.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
StimulantsChildren.pdfpdf
Relistor.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Retin-A.pdfpdf
Sutent.pdfpdf
Regranex.pdfpdf
Somavert.pdfpdf
Ziana.pdfpdf
Xibrom.pdfpdf
Uloric.pdfpdf
XanaxXR.pdfpdf
Vpriv.pdfpdf
Vectibix.pdfpdf
Xyrem.pdfpdf
Xifaxan.pdfpdf
Zavesca.pdfpdf
Vivitrol.pdfpdf
Xolegel.pdfpdf
ZoviraxOintment.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Xolair.pdfpdf
Olysio.pdfpdf
Sovaldi.pdfpdf
Oxandrin.pdfpdf
Colchicine.pdfpdf
Harvoni.pdfpdf
PPI.pdfpdf
Topical Immunomodulators.pdfpdf
Zenzedi.pdfpdf
Synagis.pdfpdf
Viekira Pak.pdfpdf
Xarelto.pdfpdf
Grastek.pdfpdf
Ragwitek.pdfpdf
Cosentyx Plaque Psoriasis DRAFT.pdfpdf
Rituxan RA 2014-12-26.pdfpdf
Remicade PP 2014-12-26.pdfpdf
Cimzia RA & PA 2014-12-26.pdfpdf
Enbrel all indications 2014-12-26.pdfpdf
Orencia RA & JIA 2014-12-26.pdfpdf
Remicade RA, PA & AS 2014-12-26.pdfpdf
Simponi RA, PA & AS 2014-12-26.pdfpdf
Simponi UC 2014-12-26.pdfpdf
Kineret RA 2014-12-26.pdfpdf
Humira UC 2014-12-26.pdfpdf
Humira RA, PA, AS & PP 2014-12-26.pdfpdf
Humira Crohns 2014-12-26.pdfpdf
Xeljanz RA 2014-12-26.pdfpdf
Cimzia Crohns 2014-12-26.pdfpdf
Arava RA 2014-12-26.pdfpdf
Actemra RA, PA & JIA 2014-12-26.pdfpdf
MS Oral Drugs DRAFT 2015-02-12.pdfpdf