Medication & Pharmacy Information
- Pharmacy Prior Authorization Forms
- Formulary Change Notice– July 2, 2020
Commercial Groups
- These plans will use the U of U Health Plans Commercial Preferred Drug List (PDL) – Please note that the PDL is subject to change
- Search Commercial PDL
- Review Commercial PDL – pdf (*use “
ctrl F” to search)
- Request Pharmacy Prior Authorization - This is for medications listed with any special requirements such as a Tier 4 Specialty, Quantity Limits, and Step Therapy
- Seasonal Prior Authorization Forms
- Submit an Exception Request - This is for exception requests for coverage of medications
- Formulary Requests
Healthy U Medicaid
- This plan will use the Healthy U Preferred Drug List (PDL) – Please note that the PDL is subject to change.
- Search the Healthy U PDL
- Review the Healthy U PDL- pdf (*use “
ctrl F” to search)
- Request Pharmacy Prior Authorization - This is for medications listed with any special requirements such as a Tier 4 Specialty, Quantity Limits, and Step Therapy
- Seasonal Prior Authorization Forms
- Formulary Requests
Individual and Family Plans
These plans will use the U of U Health Plans Individual & Family Plans Preferred Drug List (PDL) – Please note that the PDL is subject to change- Individual & Family Plans PDL Commercial PDL – pdf (*use “ctrl F” to search):
- Request Pharmacy Prior Authorization - This is for medications listed with any special requirements such as a Tier 4 Specialty, Quantity Limits, and Step Therapy
- Seasonal Prior Authorization Forms
- Submit an Exception Request - This is for exception requests for coverage of medications
- Formulary Requests
- 2018-2019 Synagis Form
Mountain Health Co-Op
Please see the Mountain Health Co-Op website for more information
University of Utah Health Employee Plan
- This plans will use the University of Utah Health Plans Employee Plan Formulary – Please note that the PDL is subject to change
- Request Pharmacy Prior Authorization - This is for medications listed with any special requirements such as a Tier 4 Specialty, Quantity Limits, and Step Therapy
- Seasonal Prior Authorization Forms
- Formulary Requests
