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.
  • For other complaints, please use the Customer Complaint Form.

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)

Member Information

Appeal Submitter Information

Provider Information


Appeal Information

If your appeal is about a service you get that is ending or being reduced do you want to get the service during the appeal review? You will need to file your appeal within 10 calendar days of the Notice of Action or the intended date of Healthy U planned action. You can choose to keep getting service(s) during your appeal but you might have to pay for them if we do not decide in your favor.
You have the right to submit comments, documents or information relevant to the appeal. Do you have more information you would like to send for the appeal? You can attach records below.
Is this related to a clinical trial?

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
6056 S. Fashion Square Drive, Suite 3940
Murray, UT 84107