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
Physician Administered Review Request Form.pdfpdf
72 Hour Supply.pdfpdf
Brand Name.pdfpdf
Buprenorphine_Naloxone.pdfpdf
Combo Product.pdfpdf
Dosing Kit.pdfpdf
New to Market Drugs.pdfpdf
Non-preferred PA.pdfpdf
Preferred Step Through.pdfpdf
Quantity Override Request.pdfpdf
Faserna (benralizumab).pdfpdf
Kymriah (tisagenlecleucel).pdfpdf
Emflaza (deflazacort).pdfpdf
Exondys 51 (eteplirsen).pdfpdf
PAMORAs.pdfpdf
Long acting opiates.pdfpdf
Aloxi (palonostron hcl).pdfpdf
Hepatitis C.pdfpdf
Kalydeco (ivacaftor).pdfpdf
Naltrexone Quantity Override.pdfpdf
Vivitrol (naltrexone er)-Sublocade (buprenorphine er).pdfpdf
Botulinum Toxins.pdfpdf
Avastin (bevacizumab).pdfpdf
Androgens.pdfpdf
Revatio (Sildenafil).pdfpdf
Adult Acne.pdfpdf
Xifaxan (rifaximin).pdfpdf
Growth Hormone.pdfpdf
Colchicine.pdfpdf
Nuvigil (armodafinil).pdfpdf
Provigil (modafinil).pdfpdf
Butrans (buprenorphine).pdfpdf
Xolair (omalizumab).pdfpdf
Zavesca (miglustat).pdfpdf
Vpriv (velaglucerase alfa).pdfpdf
Topical Immunomodulators.pdfpdf
Symlin (pramlintide).pdfpdf
Vectibix (panitumumab).pdfpdf
Synagis (palivizumab).pdfpdf
Uloric (febuxostat).pdfpdf
Tykerb (lapatinib).pdfpdf
Simvastatin.pdfpdf
Soliris (eculizumab).pdfpdf
Samsca (tolvaptan).pdfpdf
Selzentry (maraviroc).pdfpdf
Somavert (pegvisomant).pdfpdf
Sutent (sunitinib).pdfpdf
Sirturo (bedaquiline).pdfpdf
Retin-A (tretinoin gel).pdfpdf
Ragwitek.pdfpdf
Regranex (becaplermin).pdfpdf
Qualaquin (quinine).pdfpdf
Prolastin-Zemaira.pdfpdf
PPI.pdfpdf
PCSK9 inhibitors.pdfpdf
Panretin (Alitretinoin).pdfpdf
Oxandrin (oxandrolone).pdfpdf
Oralair.pdfpdf
ORKAMBI (lumacaftor-ivacaftor).pdfpdf
Nexavar (sorafenib).pdfpdf
Methadone.pdfpdf
Lidocaine (Topical).pdfpdf
Ketorolac.pdfpdf
Krystexxa (pegloticase).pdfpdf
Istodax (romidepsin).pdfpdf
Increlex (mecasermin).pdfpdf
Hydroxyprogesterone Caproate.pdfpdf
Forteo (teriparatide).pdfpdf
Gabapentin ER (Gralise or Horizant).pdfpdf
Grastek Immunotherapy.pdfpdf
Fabrazyme (agalsidase beta).pdfpdf
Entresto (sacubitril-valsartan).pdfpdf
Emsam (selegiline).pdfpdf
Emend (aprepitant).pdfpdf
Cytogam (cytomegalovirus immune globulin).pdfpdf
Cycloset (bromocriptine).pdfpdf
Cerezyme (imiglucerase).pdfpdf
Butalbital Products.pdfpdf
Aralast (alpha1-proteinase inhibitor (human) liquid).pdfpdf
Ampyra (dalfampridine).pdfpdf
Aldurazyme (laronidase).pdfpdf
Adagen (pegademase bovine).pdfpdf
Adcirca (tadalafil).pdfpdf
Growth Hormone AIDS.pdfpdf
Dupixent.pdfpdf
Xyrem (sodium oxybate).pdfpdf
Hyaluronic Acid.pdfpdf
Xibrom (bromfenac).pdfpdf
Restasis (Cyclosporine Ophthalmic Emulsion).pdfpdf