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