Please Note: Use this form to appeal a retail pharmacy adverse benefit determination (denied or limited
authorization request) or a claim benefit denial where the member could be liable for payment.
Retail Pharmacy: A medication dispensed to a member from a retail or specialty pharmacy.
Medical Pharmacy: A medication administered to a member in a facility setting (provider or infusion center) or in the home dispensed from a home infusion pharmacy.
For medical pharmacy appeals please use the University of UtahHealth Plans Appeal 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.
For all other appeals, Please use the Appeal 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.
If you need help filling out this form, call us at 855-447-2900 (TTY Users: 800-346-4128, or dial 711).