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
Aralast.pdfpdf
Cerezyme.pdfpdf
AdultAcne.pdfpdf
Ampyra.pdfpdf
Arixtra.pdfpdf
72HourSupply.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
AntiEmeticIVforNTM.pdfpdf
AntibioticsIVforNTM.pdfpdf
Adagen.pdfpdf
Aranesp.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
BrandNameMedication.pdfpdf
Aldurazyme.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Chantix.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
MetabolicSupplements.pdfpdf
Emsam.pdfpdf
NonPreferredDrugAuth.pdfpdf
Cytogam.pdfpdf
Increlex.pdfpdf
GrowthHormoneAIDS.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Lactulose.pdfpdf
Istodax.pdfpdf
Nucynta.pdfpdf
MSBiologicsNTM.pdfpdf
Fabrazyme.pdfpdf
Emend.pdfpdf
Embeda.pdfpdf
Innohep.pdfpdf
Ketorolac.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Combunox.pdfpdf
InsulinPens.pdfpdf
GrowthHormone.pdfpdf
DepoProvera.pdfpdf
HeparinNTM.pdfpdf
Erythropoetins.pdfpdf
Nexavar.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Hepsera.pdfpdf
EpinephrineNTM.pdfpdf
Cycloset.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
Krystexxa.pdfpdf
Sutent.pdfpdf
Regranex.pdfpdf
Somavert.pdfpdf
Selzentry.pdfpdf
Raptiva.pdfpdf
Samsca.pdfpdf
Trizivir.pdfpdf
StimulantsAdults.pdfpdf
Salagen.pdfpdf
Provigil.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Simvastatin.pdfpdf
NucyntaER.pdfpdf
Nuvigil.pdfpdf
Tykerb.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
StimulantsChildren.pdfpdf
Relistor.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Retin-A.pdfpdf
Xibrom.pdfpdf
Uloric.pdfpdf
XanaxXR.pdfpdf
Vpriv.pdfpdf
Vectibix.pdfpdf
Xyrem.pdfpdf
Xifaxan.pdfpdf
Zavesca.pdfpdf
Xolair.pdfpdf
Oxandrin.pdfpdf
Colchicine.pdfpdf
PPI.pdfpdf
Topical Immunomodulators.pdfpdf
Zenzedi.pdfpdf
Synagis.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Arava all indications.pdfpdf
Actemra all indications.pdfpdf
Cimzia RA & PA.pdfpdf
Cimzia Crohns.pdfpdf
Enbrel all indications.pdfpdf
Entyvio Crohns.pdfpdf
Entyvio UC.pdfpdf
Humira JIA, RA, PA, AS & PP.pdfpdf
Humira UC.pdfpdf
Kineret CAPS.pdfpdf
Kineret RA.pdfpdf
Orencia all indications.pdfpdf
Remicade RA, PA & AS.pdfpdf
Remicade Crohns.pdfpdf
Remicade PP.pdfpdf
Rituxan RA.pdfpdf
Rituxan NHL, CLL, GPA & MPA.pdfpdf
Simponi UC.pdfpdf
Simponi RA, PA & AS.pdfpdf
Stelara PA.pdfpdf
Xeljanz RA.pdfpdf
Stelara PP.pdfpdf
Otezla PP.pdfpdf
Remicade UC.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
Humira Crohns.pdfpdf
Physician Administered Review Request Form.pdfpdf
Aloxi.pdfpdf
DURBAppealRequest.pdfpdf
Oralair.pdfpdf
Restasis.pdfpdf
Avastin.pdfpdf
Grastek.pdfpdf
Hyaluronic Acid.pdfpdf
MS Oral Drugs.pdfpdf
Ragwitek.pdfpdf
Kalydeco.pdfpdf
Androgens.pdfpdf
Orkambi.pdfpdf
Vivitrol.pdfpdf
Lovenox_and_Fragmin_for_NTM.pdfpdf
Lidocaine.pdfpdf
Cosentyx PP, PA & AS.pdfpdf
Movantik.pdfpdf
PCSK9 inhibitors.pdfpdf
Entresto_draft.pdfpdf
Botulinum Toxins.pdfpdf
buprenorphine.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Xyrem PA modified criteria DRAFT.pdfpdf
Entresto.pdfpdf
Hepatitis C.pdfpdf