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 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)