Medical Drug Benefit (J Code)

All applicable Medicaid Medical Pharmacy (J Code) prior authorization requests will now be processed directly by UPHP.  Please utilize UPHP Assist Provider Portal to submit requests or fax the request form linked below for all new requests to 906-225-4516.  UPHP policy does not allow for retro-authorization (back dating) of requests.  Please utilize drug specific criteria below for your review.  Medicare Part B drugs do not require prior authorization.

*Please note that if the ancillary/service provider is not in the UPHP provider network and there is not a current out-of-network authorization, this request will not be reviewed and will be returned to the requesting provider. To verify if a provider is in the UPHP network, please review the website at  To verify if an out-of-network authorization is current please call UPHP Customer Service at: 800-835-2556.

Page Last Updated: 04/2/2024