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Utah Medicaid Prior Authorization Form

Utah Medicaid Prior Authorization Form

Updated July 27, 2023

Utah Medicaid prior authorization form is used by a medical professional who wishes to request Medicaid coverage for a non-preferred drug for a patient. In the State of Utah, drugs that are automatically covered under Medicaid are listed on the State-approved Preferred Drug List (PDL). When submitting this form, the medical professional should attach any medical documents that support their justification for making this request. If you need more information, call Utah Medicaid at the phone number provided below.

Fax – 1 (855) 828-4992

Phone – 1 (800) 662-9651

Preferred Drug List – Acceptable drugs by the State