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
MetabolicSupplements.pdfpdf
Aralast.pdfpdf
Emsam.pdfpdf
Ziana.pdfpdf
Selzentry.pdfpdf
Cytogam.pdfpdf
Rituxan RA 2014-12-26.pdfpdf
Cimzia Crohns 2014-12-26.pdfpdf
Raptiva.pdfpdf
MS Oral Drugs DRAFT 2015-02-12.pdfpdf
Increlex.pdfpdf
Omontys.pdfpdf
Innohep.pdfpdf
Samsca.pdfpdf
Xibrom.pdfpdf
GrowthHormoneAIDS.pdfpdf
Cerezyme.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Uloric.pdfpdf
AdultAcne.pdfpdf
Istodax.pdfpdf
Androgens.pdfpdf
Nucynta.pdfpdf
Simponi UC 2014-12-26.pdfpdf
MSBiologicsNTM.pdfpdf
Lactulose.pdfpdf
Oxandrin.pdfpdf
Fabrazyme.pdfpdf
XanaxXR.pdfpdf
Ampyra.pdfpdf
Emend.pdfpdf
72HourSupply.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
Vpriv.pdfpdf
Arava RA 2014-12-26.pdfpdf
Trizivir.pdfpdf
Arixtra.pdfpdf
StimulantsAdults.pdfpdf
Embeda.pdfpdf
Salagen.pdfpdf
Vectibix.pdfpdf
Colchicine.pdfpdf
Provigil.pdfpdf
Topical Immunomodulators.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Ketorolac.pdfpdf
Xyrem.pdfpdf
LuxiqFoam.pdfpdf
AntiEmeticIVforNTM.pdfpdf
Restasis.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Simvastatin.pdfpdf
Enbrel all indications 2014-12-26.pdfpdf
Orencia RA & JIA 2014-12-26.pdfpdf
Harvoni.pdfpdf
Combunox.pdfpdf
InsulinPens.pdfpdf
Cimzia RA & PA 2014-12-26.pdfpdf
Synagis.pdfpdf
Lamisil.pdfpdf
Humira Crohns 2014-12-26.pdfpdf
AntibioticsIVforNTM.pdfpdf
Adagen.pdfpdf
Avastin.pdfpdf
GrowthHormone.pdfpdf
Grastek.pdfpdf
RemicadeJIA.pdfpdf
DepoProvera.pdfpdf
Aranesp.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Pegasys&PegIntron.pdfpdf
NucyntaER.pdfpdf
Simponi RA, PA & AS 2014-12-26.pdfpdf
Remicade PP 2014-12-26.pdfpdf
Viekira Pak.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
Zenzedi.pdfpdf
Ragwitek.pdfpdf
BrandNameMedication.pdfpdf
Pradaxa.pdfpdf
Aldurazyme.pdfpdf
Nuvigil.pdfpdf
OluxFoam.pdfpdf
Kineret RA 2014-12-26.pdfpdf
HeparinNTM.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Erythropoetins.pdfpdf
Remicade RA, PA & AS 2014-12-26.pdfpdf
Actemra RA, PA & JIA 2014-12-26.pdfpdf
Chantix.pdfpdf
Tykerb.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
Nexavar.pdfpdf
StimulantsChildren.pdfpdf
GabapentinER.pdfpdf
Aloxi.pdfpdf
Forteo.pdfpdf
Hepsera.pdfpdf
BotulinumToxins.pdfpdf
Olysio.pdfpdf
Cosentyx Plaque Psoriasis DRAFT.pdfpdf
Xifaxan.pdfpdf
Amitiza.pdfpdf
EpinephrineNTM.pdfpdf
Xarelto.pdfpdf
Relistor.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Cycloset.pdfpdf
Zavesca.pdfpdf
Xeljanz RA 2014-12-26.pdfpdf
Butrans.pdfpdf
ButalbitalProducts.pdfpdf
Vivitrol.pdfpdf
NeupogenNeulastaLeukine.pdfpdf
DURBAppealRequest.pdfpdf
Krystexxa.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
Retin-A.pdfpdf
AgeQuantityOverride.pdfpdf
Sutent.pdfpdf
Humira UC 2014-12-26.pdfpdf
Humira RA, PA, AS & PP 2014-12-26.pdfpdf
Xolair.pdfpdf
NonPreferredDrugAuth.pdfpdf
Sovaldi.pdfpdf
Regranex.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Xolegel.pdfpdf
PPI.pdfpdf
ZoviraxOintment.pdfpdf
Somavert.pdfpdf