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
Anti-Diabetic-GLP-1s.pdfpdf
BrandNameMedication.pdfpdf
Aldurazyme.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
Aralast.pdfpdf
Cerezyme.pdfpdf
AdultAcne.pdfpdf
Ampyra.pdfpdf
72HourSupply.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
MetabolicSupplements.pdfpdf
Ketorolac.pdfpdf
Innohep.pdfpdf
LowMolecularWeightHeparinsforNTM.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
Emsam.pdfpdf
NonPreferredCombo&Kit.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
Anti-Diabetic-SGLT-2s.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
Lovenox_and_Fragmin_for_NTM.pdfpdf
Lidocaine.pdfpdf
PCSK9 inhibitors.pdfpdf
Botulinum Toxins.pdfpdf
buprenorphine.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Entresto.pdfpdf
Adcirca PA.pdfpdf
Revatio PA.pdfpdf
Xyrem.pdfpdf
NonPreferredDrugAuth.pdfpdf
PPI.pdfpdf
Movantik.pdfpdf
Hepatitis C.pdfpdf