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.
For Retail Pharmacy appeals (a medication dispensed to a member from a retail or specialty pharmacy), please use the Retail Pharmacy Appeal Form.
For Medical Pharmacy appeals (a medication administered to a member in a facility setting (provider or infusion center) or in the home dispensed from a home infusion pharmacy). Please use this form.
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form found here.
For other complaints, please use the Customer Complaint Form.

If you need help filling out the form, call us at 855-447-2900 (TTY Users: 800-346-4128, or dial 711).

Member Information

Provider Information

Appeal Information

Appeal Documents

If you would prefer to fax the information to the Appeals Team, please use fax # 801-587-9985.

If you would prefer to mail the information to the Appeals Team, please use:
Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107