The following forms may be helpful to you. Go to the appropriate link to download printable copies*.
Pre-Auth Form - Use this form to get prior authorization for certain
services. Complete this form and fax or mail to:
| FAX: | 1-866-472-9481 | |
| MAIL: | Healthy Advantage (HMO) Medicare | |
| 7050 S Union Park Center, Suite 200 | ||
| Midvale, Utah 84047 |
Drug Authorization Request Form - Use this form to get prior authorization of certain prescription drug benefits. Complete this form and fax or mail to:
| FAX: | 1-866-290-1309 | |
| MAIL: | Healthy Advantage (HMO) Medicare | |
| 7050 S Union Park Center, Suite 200 | ||
| Midvale, Utah 84047 |
Drug Determination Request Form - Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy. Complete this form and mail or fax to:
| FAX: | 1-866-290-1390 | |
| MAIL: | Healthy Advantage (HMO) Medicare | |
| 7050 S Union Park Center, Suite 200 | ||
| Midvale, Utah 84047 |
Paper copies of information posted on our web site are available upon request.
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