CurrentSelectHealthPolicy N/A

UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

A standardized pharmacy prior authorization (PA) request form for submitting medication PA requests to SelectHealth, including patient/prescriber data, drug information, clinical rationale, and disposition fields. Provides instructions for submission and special notes about opioid-dependence medications and SUD medications as of January 1, 2020.

Policy Summary

PayerSelectHealth

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionComplete the form in its entirety and submit via fax to SelectHealth at 801-650-3279; call 800-538-5038 for questions.

SourceLink

POLICY UPDATE CHANGES

As of January 1, 2020, no prior authorization shall be imposed for FDA-approved prescription medications on the formulary which are approved to treat substance use disorders.

801-650-3279Fax number for PA submission

800-538-5038Phone number for questions

5-dayOpioid dependence initial supply exempt from PA

Policy overview

This document is a standardized pharmacy prior authorization (PA) request form used to submit medication PA requests to SelectHealth; it captures patient, prescriber, and drug information, clinical rationale, and disposition fields to support pharmacy benefit prior authorization decisions.

Policy Summary

PayerSelectHealth

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionComplete the form in its entirety and submit via fax to SelectHealth at 801-650-3279; call 800-538-5038 for questions.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

The form instructs providers to complete it in its entirety and submit via fax to SelectHealth at 801-650-3279 and to call 800-538-5038 with questions. It collects detailed patient and prescriber identifiers, drug details (including J-code when applicable), diagnosis and ICD codes, clinical justification, prior medication history, delivery location, and prescriber signature and date.

Status: CURRENT. Subject: Uniform Pharmacy Prior Authorization Request Form. As of January 1, 2020, there is a statutory exception: no prior authorization shall be imposed for FDA-approved formulary medications approved to treat substance use disorders; additionally, if this is the first request within a 12-month period for an opioid-dependence medication, authorization is not required for a 5-day supply.

Key metadata

PayerSelectHealth

PolicyUNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM

Policy NumberN/A

StatusCURRENT

SubjectUniform Pharmacy Prior Authorization Request Form

Scope SummaryA standardized pharmacy prior authorization (PA) request form for submitting medication PA requests to SelectHealth, including patient/prescriber data, drug information, clinical rationale, and disposition fields. Provides instructions for submission and special notes about opioid-dependence medications and SUD medications as of January 1, 2020.

When prior authorization is required and exceptions

Actions required of submitting providers

Prior Authorization

Submit PA via fax

Complete the form in its entirety and submit via fax to Select Health at 801-650-3279. Call 800-538-5038 if you have questions about this form.

Fax: 801-650-3279
Phone: 800-538-5038

Documentation Required

Provide clinical justification and trial history

Provide required clinical criteria for approval, including other medications tried (names, duration, and patient response), patient diagnosis with ICD diagnostic code(s), and clinical trial registration number if the request is for use in a clinical trial.

Billing Rule

Include J-code when applicable

List the requested drug(s) and include the J-code if applicable. Provide strength, route, frequency, unit/volume, start date and length of therapy for each requested medication.

Documentation Required

Signature required

Prescriber or authorized signature and date are required on the form for submission.

Relevant codes

J-codes (if applicable)HCPCS

No codes listed

ICD-10 diagnostic codesICD-10

No codes listed

Definitions & background

As of January 1, 2020, no prior authorization requirement shall be imposed by a carrier for any FDA-approved prescription medication on its formulary which is approved to treat substance use disorders; if this is the first request within a 12-month period for a drug for opioid dependence, authorization is not required for a 5-day supply of any FDA‑approved medication for treatment of opioid dependence and there is no need to complete this form.

Urgent request: A request that, if determined in the time allowed for non-urgent requests, could seriously jeopardize life or health or the ability to regain maximum function.

Document changes

clarified

As of January 1, 2020, no prior authorization shall be imposed for FDA-approved formulary medications approved to treat substance use disorders. (is_material)

clarified

If this is the first request within a 12-month period for a drug for opioid dependence, authorization is not required for a 5-day supply of any FDA-approved medication for treatment of opioid dependence and there is no need to complete this form.

At-a-glance submission details

Quick stats

Fax number for PA submission801-650-3279

Phone number for questions800-538-5038

Opioid dependence initial supply exempt from PA5-day