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.
A medication dispensed to a member from a retail or specialty 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 Utah Health Plans Appeal Form
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form
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 877-358-8797. (Si necesita ayuda para llenar o completar este formulario, llamenos al 877-358-8797)
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