Utah Medicaid Prior Authorization Form

Updated January 24, 2022

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

How to Write

Step 1 – Download and open the PDF version of the Utah Medicaid Prior Authorization Form.

Step 2 – Enter the patient’s name and Medicaid ID number into the indicated spaces.

Step 3 – Next, provide the prescriber’s name, NPI number, contact person, phone number (and extension), and fax number.

Step 4 – If known, enter the pharmacy name, phone number, and fax number.

Step 5 – Below that, enter the name, strength, and frequency per day of the requested prescription.

Step 6 – Print and sign the form.

Step 7 – Attach any relevant supporting medical documentation and fax the completed form (and attachments) to the appropriate directory.