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Utah Medicaid Prior Authorization Form

Utah Medicaid prior authorization form is used by a medical professional to request Medicaid coverage for a patient's non-preferred drug, which is a medication that does not appear on the preferred drug list. When submitting this form, the physician must also submit their medical reasoning for prescribing the non-preferred medication.
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Fax – 1 (855) 828-4992

Phone – 1 (800) 662-9651

Preferred Drug List – Acceptable drugs by the State