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
ZoviraxOintment.pdfpdf
Ziana.pdfpdf
Zenzedi.pdfpdf
Zavesca.pdfpdf
Xyrem.pdfpdf
Xolegel.pdfpdf
Xolair.pdfpdf
Xifaxan.pdfpdf
Xibrom.pdfpdf
Xeljanz RA.pdfpdf
Xarelto.pdfpdf
XanaxXR.pdfpdf
Vpriv.pdfpdf
Vivitrol.pdfpdf
Viekira Pak.pdfpdf
Vectibix.pdfpdf
Uloric.pdfpdf
Tykerb.pdfpdf
Trizivir.pdfpdf
Topical Immunomodulators.pdfpdf
Synagis.pdfpdf
Symlin.pdfpdf
Sutent.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
StimulantsChildren.pdfpdf
StimulantsAdults.pdfpdf
Stelara PP.pdfpdf
Stelara PA.pdfpdf
Sovaldi.pdfpdf
Somavert.pdfpdf
Soliris.pdfpdf
Sirturo.pdfpdf
Simvastatin.pdfpdf
Simponi UC.pdfpdf
Simponi RA, PA & AS.pdfpdf
Selzentry.pdfpdf
Samsca.pdfpdf
Salagen.pdfpdf
Rituxan RA.pdfpdf
Rituxan NHL, CLL, GPA & MPA.pdfpdf
Retin-A.pdfpdf
Restasis.pdfpdf
Remicade UC.pdfpdf
Remicade RA, PA & AS.pdfpdf
Remicade PP.pdfpdf
Remicade Crohns.pdfpdf
Relistor.pdfpdf
Regranex.pdfpdf
Raptiva.pdfpdf
Ragwitek.pdfpdf
Qualaquin.pdfpdf
Provigil.pdfpdf
Prolastin&Zemaira.pdfpdf
Pradaxa.pdfpdf
PPI.pdfpdf
Physician Administered Review Request Form.pdfpdf
Pegasys&PegIntron.pdfpdf
Panretin.pdfpdf
Oxandrin.pdfpdf
Otezla PP.pdfpdf
Orencia all indications.pdfpdf
Olysio.pdfpdf
OluxFoam.pdfpdf
Nuvigil.pdfpdf
NucyntaER.pdfpdf
Nucynta.pdfpdf
NonPreferredDrugAuth.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Nexavar.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
MSBiologicsNTM.pdfpdf
MS Oral Drugs.pdfpdf
MetabolicSupplements.pdfpdf
LuxiqFoam.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Lamisil.pdfpdf
Lactulose.pdfpdf
Krystexxa.pdfpdf
Kineret RA.pdfpdf
Kineret CAPS.pdfpdf
Ketorolac.pdfpdf
Istodax.pdfpdf
InsulinPens.pdfpdf
Innohep.pdfpdf
Increlex.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Humira UC.pdfpdf
Humira JIA, RA, PA, AS & PP.pdfpdf
Humira Crohns.pdfpdf
Hepsera.pdfpdf
HeparinNTM.pdfpdf
Harvoni.pdfpdf
GrowthHormoneAIDS.pdfpdf
GrowthHormone.pdfpdf
Grastek.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Fabrazyme.pdfpdf
Erythropoetins.pdfpdf
EpinephrineNTM.pdfpdf
Entyvio UC.pdfpdf
Entyvio Crohns.pdfpdf
Enbrel all indications.pdfpdf
Emsam.pdfpdf
Emend.pdfpdf
Embeda.pdfpdf
DURBAppealRequest.pdfpdf
DepoProvera.pdfpdf
Cytogam.pdfpdf
Cymbalta quantity override.pdfpdf
Cycloset.pdfpdf
Cosentyx Plaque Psoriasis.pdfpdf
Combunox.pdfpdf
Colchicine.pdfpdf
Cimzia RA & PA.pdfpdf
Cimzia Crohns.pdfpdf
Chantix.pdfpdf
Cerezyme.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
BrandNameMedication.pdfpdf
BotulinumToxins.pdfpdf
Avastin.pdfpdf
Arixtra.pdfpdf
Arava all indications.pdfpdf
Aranesp.pdfpdf
Aralast.pdfpdf
AntiEmeticIVforNTM.pdfpdf
AntibioticsIVforNTM.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Androgens.pdfpdf
Ampyra.pdfpdf
Amitiza.pdfpdf
Aloxi.pdfpdf
Aldurazyme.pdfpdf
AgeQuantityOverride.pdfpdf
AdultAcne.pdfpdf
Adagen.pdfpdf
Actemra all indications.pdfpdf
72HourSupply.pdfpdf