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
Adagen.pdfpdf
Aldurazyme.pdfpdf
ButalbitalProducts.pdfpdf
Aralast.pdfpdf
Cerezyme.pdfpdf
AdultAcne.pdfpdf
Ampyra.pdfpdf
MetabolicSupplements.pdfpdf
GrowthHormone.pdfpdf
Nexavar.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Krystexxa.pdfpdf
Cytogam.pdfpdf
Increlex.pdfpdf
GrowthHormoneAIDS.pdfpdf
Istodax.pdfpdf
Fabrazyme.pdfpdf
Provigil.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Simvastatin.pdfpdf
Tykerb.pdfpdf
Nuvigil.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Retin-A.pdfpdf
Sutent.pdfpdf
Regranex.pdfpdf
Somavert.pdfpdf
Selzentry.pdfpdf
Samsca.pdfpdf
Xifaxan.pdfpdf
Zavesca.pdfpdf
Xibrom.pdfpdf
Uloric.pdfpdf
Vectibix.pdfpdf
Vpriv.pdfpdf
Oxandrin.pdfpdf
Colchicine.pdfpdf
Topical Immunomodulators.pdfpdf
Synagis.pdfpdf
Physician Administered Review Request Form.pdfpdf
Oralair.pdfpdf
Restasis.pdfpdf
Grastek.pdfpdf
Hyaluronic Acid.pdfpdf
Ragwitek.pdfpdf
Orkambi.pdfpdf
PCSK9 inhibitors.pdfpdf
Xyrem.pdfpdf
Revatio.pdfpdf
PPI.pdfpdf
Entresto.pdfpdf
Adcirca.pdfpdf
Ketorolac.pdfpdf
Cycloset.pdfpdf
Emsam.pdfpdf
Butrans.pdfpdf
Emend.pdfpdf
Xolair.pdfpdf
Methadone.pdfpdf
Vivitrol.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Avastin.pdfpdf
Lidocaine.pdfpdf
72 Hour Supply.pdfpdf
Brand Name.pdfpdf
Buprenorphine_Naloxone.pdfpdf
Combo Product.pdfpdf
Dosing Kit.pdfpdf
Dupixent.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
Botulinum Toxins.pdfpdf
Aloxi (palonostron hcl).pdfpdf
Hepatitis C.pdfpdf
Kalydeco (ivacaftor).pdfpdf
Naltrexone Quantity Override.pdfpdf
Androgens.pdfpdf