About the Health Choice Utah Formulary
The Health Choice Utah Formulary is your guide to prescription drugs covered by Health Choice Utah. The Formulary is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by their generic name. Brand name products are included as a reference to assist in product recognition. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are covered. In addition, the formulary covers selected over-the-counter (OTC) products.
Here is how you can view or search the Formulary:
Visit the Comprehensive Formulary page
Health Choice may add or remove drugs from our formulary during the year. Members affected by formulary changes will be notified through a letter prior to the change. To get updated information about drugs covered by Health Choice Utah or to get a printed copy of the formulary, please use the formulary links above or call Pharmacy Customer Service at 855-864-1404 toll-free, 24 hours a day, 7 days a week, and 365 days a year. (TTY/TDD users can call 711).
Opioid Prescribing Guidelines
Controlled Substance Prescribing and Monitoring
Utah state law now requires that providers check the Utah Department of Professional Licensing Controlled Substance Database (CSDB) prior to prescribing controlled substances to a patient for the first time. Prescription monitoring limits dispensing to patients seeking prescriptions from multiple prescribers and helps to identify patients who may be struggling with addiction. Providers and their staff can learn more about the program and apply here.
Also, first-time controlled substance prescriptions are limited to a seven-day supply for individuals being treated for acute, nonsurgical pain.
Prescriber Education
Utah state law establishes the continuing education requirements for controlled substance prescribers under the Utah Controlled Substances Act. It requires certain controlled substance prescribers to complete at least 3.5 hours of continuing education hours in one or more controlled substance prescribing classes as a requisite for license renewal. In addition to other requirements, the controlled substance prescribing class should also include all elements of the FDA Blueprint for Prescriber Education under the FDA’s Extended-Release and Long-Acting Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS).
Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain
The Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain (Guidelines) provide recommendations for the use of opioids for management of pain that are intended to balance the benefits of use against the risks to the individual and society.
Requirements or Limits on Coverage
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization
Health Choice Utah may require prior authorization for certain drugs. Prior authorization will need to be obtained for medications noted with a “PA” in the drug list and for all unlisted medications. Providers need to get approval from Health Choice Utah before prescriptions are filled. Please refer to the Health Choice Utah Formulary to find out if a drug requires Prior Authorization.
For your convenience, click here to obtain the Medication Prior Authorization Form.
For Formulary Exception Requests, click here to obtain the Formulary Exception Request Form.
You can also request a Retail Pharmacy Prior Authorization or exception by submitting the Retail Pharmacy Prior Authorization Criteria form.
Note: Pharmacy prior authorization ONLY. Medical prior authorization requests (including J-code) may be submitted via the Provider Portal.
Quantity Limits
For certain drugs, Health Choice Utah may limit the amount of the drug that our plan will cover. Please refer to the Health Choice Formulary to find out if a drug has quantity limits.
Step Therapy
In some cases, Health Choice may require a member to try certain drugs to treat a medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, Health Choice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Health Choice will then cover Drug B. Please refer to the Health Choice Formulary to find out if a drug has additional requirements or limits.