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
DURBAppealRequest.pdfpdf
Xibrom.pdfpdf
Krystexxa.pdfpdf
Anti-Diabetic-SGLT-2s.pdfpdf
Retin-A.pdfpdf
Enbrel all indications.pdfpdf
AgeQuantityOverride.pdfpdf
Sutent.pdfpdf
Xolair.pdfpdf
NonPreferredDrugAuth.pdfpdf
Sovaldi.pdfpdf
Kalydeco.pdfpdf
Regranex.pdfpdf
Lactulose.pdfpdf
HydroxyprogesteroneCaproate.pdfpdf
Xolegel.pdfpdf
PPI.pdfpdf
ZoviraxOintment.pdfpdf
Somavert.pdfpdf
Aralast.pdfpdf
Rituxan NHL, CLL, GPA & MPA.pdfpdf
Ziana.pdfpdf
Selzentry.pdfpdf
Cytogam.pdfpdf
Arixtra.pdfpdf
Remicade UC.pdfpdf
Raptiva.pdfpdf
Increlex.pdfpdf
Samsca.pdfpdf
Cymbalta quantity override.pdfpdf
GrowthHormoneAIDS.pdfpdf
Cerezyme.pdfpdf
NonPreferredCombo&Kit.pdfpdf
Uloric.pdfpdf
AdultAcne.pdfpdf
Entyvio Crohns.pdfpdf
Istodax.pdfpdf
Androgens.pdfpdf
Nucynta.pdfpdf
MS Oral Drugs.pdfpdf
MSBiologicsNTM.pdfpdf
Oxandrin.pdfpdf
Fabrazyme.pdfpdf
XanaxXR.pdfpdf
Ampyra.pdfpdf
Emend.pdfpdf
Vectibix.pdfpdf
72HourSupply.pdfpdf
Hyaluronic Acid.pdfpdf
Anti-Diabetic-TZDs.pdfpdf
Vpriv.pdfpdf
Trizivir.pdfpdf
StimulantsAdults.pdfpdf
Embeda.pdfpdf
Salagen.pdfpdf
Colchicine.pdfpdf
Provigil.pdfpdf
Topical Immunomodulators.pdfpdf
Qualaquin.pdfpdf
Prolastin&Zemaira.pdfpdf
Ketorolac.pdfpdf
Innohep.pdfpdf
Orkambi.pdfpdf
LuxiqFoam.pdfpdf
Humira JIA, RA, PA, AS & PP.pdfpdf
AntiEmeticIVforNTM.pdfpdf
Orencia all indications.pdfpdf
Restasis.pdfpdf
LowMolecularWeightHeparinsforNTM.pdfpdf
Simvastatin.pdfpdf
Harvoni.pdfpdf
Combunox.pdfpdf
Xyrem.pdfpdf
Stelara PP.pdfpdf
Cimzia Crohns.pdfpdf
Lidocaine.pdfpdf
InsulinPens.pdfpdf
Botulinum Toxins.pdfpdf
Synagis.pdfpdf
Lamisil.pdfpdf
AntibioticsIVforNTM.pdfpdf
Adagen.pdfpdf
Avastin.pdfpdf
Aranesp.pdfpdf
Physician Administered Review Request Form.pdfpdf
Lovenox_and_Fragmin_for_NTM.pdfpdf
GrowthHormone.pdfpdf
Grastek.pdfpdf
Humira UC.pdfpdf
DepoProvera.pdfpdf
Suboxone&Zubsolv&Bunavail.pdfpdf
Xeljanz RA.pdfpdf
NucyntaER.pdfpdf
Remicade RA, PA & AS.pdfpdf
Simponi UC.pdfpdf
Entyvio UC.pdfpdf
Viekira Pak.pdfpdf
Anti-Diabetic-GLP-1s.pdfpdf
Zenzedi.pdfpdf
Ragwitek.pdfpdf
BrandNameMedication.pdfpdf
buprenorphine.pdfpdf
Aldurazyme.pdfpdf
Nuvigil.pdfpdf
OluxFoam.pdfpdf
Tykerb.pdfpdf
Kineret CAPS.pdfpdf
Rituxan RA.pdfpdf
HeparinNTM.pdfpdf
Anti-Diabetic-DPP-4s.pdfpdf
Erythropoetins.pdfpdf
Actemra all indications.pdfpdf
Chantix.pdfpdf
Cosentyx Plaque Psoriasis.pdfpdf
Symlin.pdfpdf
Soliris.pdfpdf
Cimzia RA & PA.pdfpdf
Nexavar.pdfpdf
StimulantsChildren.pdfpdf
GabapentinER.pdfpdf
Aloxi.pdfpdf
Humira Crohns.pdfpdf
Forteo.pdfpdf
Hepsera.pdfpdf
Olysio.pdfpdf
PCSK9 inhibitors 2016-01-19 DRAFT.pdfpdf
Xifaxan.pdfpdf
Butrans.pdfpdf
Amitiza.pdfpdf
EpinephrineNTM.pdfpdf
Stelara PA.pdfpdf
Movantik PA Criteria DRAFT 2016-01-13.pdfpdf
Oralair.pdfpdf
Simponi RA, PA & AS.pdfpdf
Relistor.pdfpdf
Sirturo.pdfpdf
Panretin.pdfpdf
Cycloset.pdfpdf
Emsam.pdfpdf
Remicade Crohns.pdfpdf
Zavesca.pdfpdf
Remicade PP.pdfpdf
Arava all indications.pdfpdf
Otezla PP.pdfpdf
ButalbitalProducts.pdfpdf
Vivitrol.pdfpdf
Kineret RA.pdfpdf
NeupogenNeulastaLeukine.pdfpdf