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2022 $0 Out-of-Pocket Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2022 Individual & Small Groups Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2023 $0 Out-of-Pocket Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2023 Employer Application For Group
2023 Individual & Small Groups Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2024 $0 Out-of-Pocket Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2024 Employer Application For Group
2024 Individual & Small Groups Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
AMA Guide for No Surprises Act Disputes
Appeal Form
Behavioral Health Provider Policies
Residential Treatment Center (RTC) Requirements Policy
Behavioral Health/Substance Request Form
Broker Media Kit
Training for Brokers.
Claim Denial: External Review Request Form
If you appeal a claim and were still denied you can request a review of the circumstances. In most cases, before filing an external review, you must first exhaust your internal grievance and appeal rights.
Claim Denial: Incapacitation Review
If you appeal a claim and were still denied you can request a review of the circumstances. In most cases, before filing an external review, you must first exhaust your internal grievance and appeal rights.
Claims Submission
Claims should be submitted through our plan administrator’s clearinghouse, the Utah Health Information Network (UHIN). More details: http://www.uhin.org/
Consent Form
Employee Census Form (Excel Download)
File an Appeal
Please Note: Use this form to appeal an adverse benefit determination (denied or limited authorization request) or a claim benefit denial where the member could be liable for payment.
Formulary Change Notice
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
Formulary Exception Request Form
Suitable for faxing
Formulary Exception Request Form
To request a drug formulary not listed on MHC Formulary List. To view formulary list and complete pharmacy details View Pharmacy Page.
Home Health Care Request Form
For a better experience, complete your request here Or you may fax your request: 801-213-1358. Please include this document at the front of your submission.
Hospice Care Request Form
Large Group - Commercial Prescription Drugs List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
Location Add/Change Form
Use this form to add a location, change location, and change billing information.
Medical Claim Form
The best way to manage claims is in the Member Portal.
Medical Documentation Submission Form
Use this form, along with missing documentation, for MDOC claim denials.
Medical Provider Policy
The University of Utah Health Plans ® Medical Policy Manual and Coding/Reimbursement Policy Manual contain policies approved by U of U Health Plans.
Member Welcome Guide
Your definitive guide to your new health plan.
MRI Criteria Guidelines
No Surprises Act Dispute Form
Non-Formulary Drug Coverage Policy
Non-Formulary Drug Coverage Policy
To view formulary list and complete pharmacy details View Pharmacy Page.
Open Negotiation Notice Instructions (submit to [email protected] only)
The Open Negotiation Notice must be submitted to [email protected] and not to University of Utah Health Plans (UUHP).
Prescription Claim Form
The best way to manage claims is in the Member Portal.
Preventive Care Guidebook
Learn about your free preventive health care benefits.
Prior Authorization E-Form
Medical Electronic Request Form (PREFERRED METHOD) for Prior Authorization
Prior Authorization Form PDF Version
(Suitable For Faxing)
Prior Authorization Form: Pharmacy
For Specialty Drug Requests. Downloadable PDF Version suitable for faxing. For more details and to view online pharmacy prior authorization version View Pharmacy Page.
Provider Add Form
Use this form to add a new provider to your already contracted group.
Provider Manual
This manual is where you can look for policies and procedures.
Provider Term Request Form
Use this form to remove a provider that has left the group.
Receiving Funds & Setting up EFT
We must have a W-9 on file before we can make any payments to you. You can fax your W-9 form to 801-281-6121. If we do not have a direct deposit set up for your group, we will send a paper check.
Release Health Info to Someone Else
Report Changes Member Form
Any life changes must be reported to your policy to ensure claims are processed properly. If you don’t report life changes, you may be at risk of claim denials.
Retail Drugs Prior Authorization & Exception Forms
Coverage Policies
Retail Pharmacy Appeal Form
Retail Pharmacy Appeal Form
Services Requiring Prior Authorization
This document is intended only to provide information related to which CPT/HCPCs codes require prior authorization. It does not indicate/list codes which may be excluded from coverage or not covered for other reasons. In addition, inclusion on this list indicates, if covered the code would require prior authorization for coverage.
Skilled Nursing Facility & Acute Rehab Request Form
Authorization Request for SNF, Acute Rehab and LTAC
Submitting Additional Documentation
For submitting additional documentation, please use the Medical Documentation Submission Form.
Utilization Mgmt. Medical Policies
We would be happy to provide you with a copy of the criteria we use to make utilization management decisions. Contact the UM team for more info: 855-447-2900 You may also email your request for criteria to [email protected]
Your Right to Appeal
Zelis Bill Review for Claim Appeal Form
Zelis Claim Appeal Submittal Form Bill Review Complete all information requested below and fax or email with a copy of complete medical records, itemized bills and a copy of the HCFA-1500 or UB-04 to (908) 658-3511 or [email protected].
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