The criteria below have been archived. They have been alphabetized for your convenience. If you have questions, contact the webmaster or call Medicaid Information at (801) 538-6155 or 1-800-662-9651.

All documentation that is required must be attached in addition to the Prior Authorization Request Form located on the Forms page.

 

 
Criteria for Medical and Surgical Procedures
   
Criteria for Imaging
   
Criteria for Medical Supplies
   
Criteria for Dental
   
Therapies and Education