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.

Get Adobe Reader

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