Prior Authorizations & Referrals

If Prior Authorization (PA) is required, the Primary Care Provider (PCP) or specialty care provider will complete the Prior Authorization Form, attach supporting documentation and fax to the Prior Authorization Department. Some medications (including non-generic medications) require Prior Authorization. To request an authorization for a medication that is not listed on the formulary but is reimbursable, please complete a non-formulary drug prior authorization and fax to the number listed within the Pharmacy Prior Authorization Form (see below).

  • Services that are outside the scope of the PCP, may be referred to a contracted specialty care provider. The PCP will complete the Referral Form or acceptable substitute and fax it to the specialty care provider’s office along with applicable test results and other pertinent documents.
  • Primary care providers, specialists, hospitals, and vendors should fax Prior Authorization requests to the Prior Authorization Department.
  • If PA is not required, per the Prior Authorization Grid, the PCP must refer the patient with a form of written instruction (i.e., note on prescription pad or Referral Form) with reason for visit (consult only – consult & treat, diagnosis, findings, etc.) to present to the specialty care provider.
  • Specialty care providers must obtain Prior Authorization from the Prior Authorization Department for all services as listed on the Prior Authorization Grid.

To request an PA, fax your request to the health plans and use the fax number on the PA form. We use RightFax Computer System, which reproduces the referral electronically. This is the preferred method for obtaining authorization. Submit your request on a completed Prior Authorization Form. Please ensure that the provider’s name and fax number are clearly noted on the form. Please note whether the request is Standard or Expedited.

Changing Prior Authorization Process

Prior authorization processes will be changing for some of your patients. Banner Health has contracted with eviCore healthcare to provide services for members enrolled in Banner – University Family Care/ACC and Banner – University Family Care/ALTCS. Learn more at the links below!

Prior Authorization Forms

Please include ALL pertinent clinical information with your Medical/Pharmacy Prior Authorization (PA) request submission. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work.

*Providers must use the “Expedited” request only when medically necessary. Note: Inappropriate Expedited requests may be downgraded to a Standard request by B – UHP.

Fax the appropriate form to:

Medical: (520) 874-3418 or (866) 210-0512

Pharmacy: (866) 349-0338 

Related Documents 

Removal of Prior Authorization Requirement for Synagis

Based on regional surveillance data, Banner – University Health Plans is pausing Prior Authorization requirements this season for Synagis® (palivizumab). Effective November 15, 2022, the Prior Authorization form for RSV prophylaxis to utilize Syangis is not required for the remainder of the 2022-23 RSV season.

Retrospective Review

Retrospective Reviews and supporting documentation/medical records should be directly submitted to B – UHP Claims department via mail or claim resubmission. Please mark claim as 'resubmission' if applicable.


Services Requiring Prior Authorization

The Prior Authorization Grids are your source for determining what services require Prior Authorization. Be sure to reference the date of the grid since revisions to the grid may occur.

Always refer to the AHCCCS Medical Policy Manual (AMPM) Chapter 300 for coverage issues: