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.pdfpdf
Xyrem.pdfpdf
Xolair.pdfpdf
Xifaxan.pdfpdf
Xibrom.pdfpdf
XanaxXR.pdfpdf
Vpriv.pdfpdf
Vivitrol.pdfpdf
Vectibix.pdfpdf
Uloric.pdfpdf
Tykerb.pdfpdf
Topical Immunomodulators.pdfpdf
Synagis.pdfpdf
Symlin.pdfpdf
Sutent.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Somavert.pdfpdf
Soliris.pdfpdf
Sirturo.pdfpdf
Simvastatin.pdfpdf
Selzentry.pdfpdf
Samsca.pdfpdf
Salagen.pdfpdf
Revatio PA.pdfpdf
Retin-A.pdfpdf
Restasis.pdfpdf
Relistor.pdfpdf
Regranex.pdfpdf
Ragwitek.pdfpdf
Qualaquin.pdfpdf
Provigil.pdfpdf
Prolastin&Zemaira.pdfpdf
PPI.pdfpdf
Physician Administered Review Request Form.pdfpdf
PCSK9 inhibitors.pdfpdf
Panretin.pdfpdf
Oxandrin.pdfpdf
Orkambi.pdfpdf
Oralair.pdfpdf
Nuvigil.pdfpdf
NonPreferredDrugAuth.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Nexavar.pdfpdf
MSBiologicsNTM.pdfpdf
Movantik.pdfpdf
MetabolicSupplements.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Lidocaine.pdfpdf
Krystexxa.pdfpdf
Ketorolac.pdfpdf
Kalydeco.pdfpdf
Istodax.pdfpdf
InsulinPens.pdfpdf
Innohep.pdfpdf
Increlex.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Hyaluronic Acid.pdfpdf
Hepatitis C.pdfpdf
HeparinNTM.pdfpdf
GrowthHormoneAIDS.pdfpdf
GrowthHormone.pdfpdf
Grastek.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Fabrazyme.pdfpdf
EpinephrineNTM.pdfpdf
Entresto.pdfpdf
Emsam.pdfpdf
Emend.pdfpdf
Embeda.pdfpdf
DepoProvera.pdfpdf
Cytogam.pdfpdf
Cycloset.pdfpdf
Colchicine.pdfpdf
Cerezyme.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
buprenorphine.pdfpdf
BrandNameMedication.pdfpdf
Botulinum Toxins.pdfpdf
Avastin.pdfpdf
Arixtra.pdfpdf
Aralast.pdfpdf
AntiEmeticIVforNTM.pdfpdf
AntibioticsIVforNTM.pdfpdf
Androgens.pdfpdf
Ampyra.pdfpdf
Aloxi.pdfpdf
Aldurazyme.pdfpdf
AdultAcne.pdfpdf
Adcirca PA.pdfpdf
Adagen.pdfpdf
72HourSupply.pdfpdf