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
Lidocaine (Topical).pdfpdf
Colchicine.pdfpdf
Growth Hormone.pdfpdf
Topical Immunomodulators.pdfpdf
Restasis (Cyclosporine Ophthalmic Emulsion).pdfpdf
Ketorolac.pdfpdf
Symlin (pramlintide).pdfpdf
Preferred Step Through.pdfpdf
Brand Name.pdfpdf
Simvastatin.pdfpdf
Emend (aprepitant).pdfpdf
Vpriv (velaglucerase alfa).pdfpdf
Xolair (omalizumab).pdfpdf
Revatio (Sildenafil).pdfpdf
72 Hour Supply.pdfpdf
Dupixent.pdfpdf
Soliris (eculizumab).pdfpdf
Samsca (tolvaptan).pdfpdf
Faserna (benralizumab).pdfpdf
Dosing Kit.pdfpdf
Botulinum Toxins.pdfpdf
Oxandrin (oxandrolone).pdfpdf
Physician Administered Review Request Form.pdfpdf
Xifaxan (rifaximin).pdfpdf
Entresto (sacubitril-valsartan).pdfpdf
Zavesca (miglustat).pdfpdf
Vivitrol (naltrexone er)-Sublocade (buprenorphine er).pdfpdf
Adagen (pegademase bovine).pdfpdf
Xyrem (sodium oxybate).pdfpdf
Nuvigil (armodafinil).pdfpdf
Selzentry (maraviroc).pdfpdf
New to Market Drugs.pdfpdf
Somavert (pegvisomant).pdfpdf
Vectibix (panitumumab).pdfpdf
Aloxi (palonostron hcl).pdfpdf
Adcirca (tadalafil).pdfpdf
Nexavar (sorafenib).pdfpdf
Emflaza (deflazacort).pdfpdf
Istodax (romidepsin).pdfpdf
Ragwitek.pdfpdf
Growth Hormone AIDS.pdfpdf
Retin-A (tretinoin gel).pdfpdf
Kalydeco (ivacaftor).pdfpdf
Emsam (selegiline).pdfpdf
Provigil (modafinil).pdfpdf
Increlex (mecasermin).pdfpdf
Hydroxyprogesterone Caproate.pdfpdf
Combo Product.pdfpdf
Regranex (becaplermin).pdfpdf
Synagis (palivizumab).pdfpdf
Forteo (teriparatide).pdfpdf
Sutent (sunitinib).pdfpdf
Butrans (buprenorphine).pdfpdf
Oralair.pdfpdf
Exondys 51 (eteplirsen).pdfpdf
Qualaquin (quinine).pdfpdf
Prolastin-Zemaira.pdfpdf
Cerezyme (imiglucerase).pdfpdf
Avastin (bevacizumab).pdfpdf
Adult Acne.pdfpdf
Uloric (febuxostat).pdfpdf
Butalbital Products.pdfpdf
Gabapentin ER (Gralise or Horizant).pdfpdf
Aralast (alpha1-proteinase inhibitor (human) liquid).pdfpdf
Fabrazyme (agalsidase beta).pdfpdf
PAMORAs.pdfpdf
Krystexxa (pegloticase).pdfpdf
Buprenorphine_Naloxone.pdfpdf
Grastek Immunotherapy.pdfpdf
Aldurazyme (laronidase).pdfpdf
Methadone.pdfpdf
Quantity Override Request.pdfpdf
PPI.pdfpdf
ORKAMBI (lumacaftor-ivacaftor).pdfpdf
PCSK9 inhibitors.pdfpdf
Xibrom (bromfenac).pdfpdf
Kymriah (tisagenlecleucel).pdfpdf
Cytogam (cytomegalovirus immune globulin).pdfpdf
Naltrexone Quantity Override.pdfpdf
Hepatitis C.pdfpdf
Ampyra (dalfampridine).pdfpdf
Sirturo (bedaquiline).pdfpdf
Androgens.pdfpdf
Long acting opiates.pdfpdf
Cycloset (bromocriptine).pdfpdf
Panretin (Alitretinoin).pdfpdf
Hyaluronic Acid.pdfpdf
Tykerb (lapatinib).pdfpdf
Non-preferred PA.pdfpdf