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
Revatio PA.pdfpdf
Retin-A.pdfpdf
Restasis.pdfpdf
Relistor.pdfpdf
Regranex.pdfpdf
Ragwitek.pdfpdf
Quantity Limits, Opioids.pdfpdf
Quantity Limits, General.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
Movantik.pdfpdf
Methadone 2016-11-10.pdfpdf
MetabolicSupplements.pdfpdf
Long Acting Opiates 2016-11-10.pdfpdf
Lidocaine.pdfpdf
Krystexxa.pdfpdf
Ketorolac.pdfpdf
Kalydeco.pdfpdf
Istodax.pdfpdf
Increlex.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Hyaluronic Acid.pdfpdf
Hepatitis C.pdfpdf
GrowthHormoneAIDS.pdfpdf
GrowthHormone.pdfpdf
Grastek.pdfpdf
GabapentinER.pdfpdf
Forteo.pdfpdf
Fabrazyme.pdfpdf
Entresto.pdfpdf
Emsam.pdfpdf
Emend.pdfpdf
Cytogam.pdfpdf
Cycloset.pdfpdf
Colchicine.pdfpdf
Cerezyme.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
Buprenorphine_Naloxone_draft.pdfpdf
buprenorphine.pdfpdf
BrandNameMedication.pdfpdf
Botulinum Toxins.pdfpdf
Avastin.pdfpdf
Aralast.pdfpdf
Androgens.pdfpdf
Ampyra.pdfpdf
Aloxi.pdfpdf
Aldurazyme.pdfpdf
AdultAcne.pdfpdf
Adcirca PA.pdfpdf
Adagen.pdfpdf
72HourSupply.pdfpdf