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
72HourSupply.pdfpdf
MetabolicSupplements.pdfpdf
InsulinPens.pdfpdf
GrowthHormone.pdfpdf
Nexavar.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Krystexxa.pdfpdf
Cytogam.pdfpdf
Increlex.pdfpdf
GrowthHormoneAIDS.pdfpdf
Istodax.pdfpdf
Fabrazyme.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
Xifaxan.pdfpdf
Zavesca.pdfpdf
Uloric.pdfpdf
XanaxXR.pdfpdf
Xibrom.pdfpdf
Vpriv.pdfpdf
Vectibix.pdfpdf
Oxandrin.pdfpdf
Colchicine.pdfpdf
Topical Immunomodulators.pdfpdf
Synagis.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
PCSK9 inhibitors.pdfpdf
Botulinum Toxins.pdfpdf
buprenorphine.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Xyrem.pdfpdf
NonPreferredDrugAuth.pdfpdf
Movantik.pdfpdf
Hepatitis C.pdfpdf
Revatio PA.pdfpdf
PPI.pdfpdf
Entresto.pdfpdf
Adcirca PA.pdfpdf
Ketorolac.pdfpdf
Cycloset.pdfpdf
Emsam.pdfpdf
BrandNameMedication.pdfpdf
Butrans.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Emend.pdfpdf
Quantity Limits, Opioids.pdfpdf
Quantity Limits, General.pdfpdf
Lidocaine.pdfpdf
Xolair.pdfpdf