Download Pharmacy Pre-authorization Forms

PEHP has chosen specific prescription drugs and specialty medications to require pre-authorization. These medications were chosen due to their high potential for safety issues, adverse reactions, contraindications, misuse, opportunity to use first line therapy, or cost.

For authorization, please download the appropriate form, answer each question, and print. Send the form and applicable patient chart notes to document clinical information. Fax the form back to the PEHP Pre-authorization Department at 801-245-7774 or mail to: PEHP Pharmacy services, 560 East 200 South Salt Lake City, UT 84102. If you have pre-authorization questions, call PEHP at 801-366-7555 or 800-765-7347.

If a medication you are prescribing is not found on this list, you may use the PEHP Case Management Medication Pre-authorization Form Please fax form and all requested documentation to the PEHP Pharmacy Department at 801-245-7774 or mail to: PEHP Pharmacy Department, 560 East 200 South, Salt Lake City, UT 84102. If you are unsure if the medication you are prescribing requires pre-authorization, or need benefit information regarding specific medications, please call PEHP at 801-366-7555 or 800-765-7347.