The criteria below have been archived.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