Medical Drug Benefit (J Code)

All applicable Medicaid Medical Pharmacy (J-Code; Q-code) prior authorization requests will now be processed directly by UPHP via the UPHP Assist Provider Portal. UPHP no longer accepts faxed prior authorization requests for medical pharmacy drugs from in-network providers. To access the UPHP Assist Provider Portal, or to become a registered user, please visit: https://www.uphp.com/provider-login/

If you are an out-of-network provider and do not wish to register in the UPHP Assist Provider Portal, you may submit requests by fax using the request form linked below 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/billing 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 www.uphp.com. To verify if an out-of-network authorization is current please call UPHP Customer Service at: 800-835-2556.

• Medical Pharmacy (J Code) Drug Prior Authorization Request Form
• Medical Pharmacy Drugs that will require a Prior Authorization for Medicaid (updated 9/25/2024)
• UPHP Assist Prior Authorization FAQ
• UPHP Medical Pharmacy Drug Criteria
  • UPHP Med Pharmacy PA Criteria J3357 Stelara SQ
  • UPHP Med Pharmacy PA Criteria J0172 Aduhelm 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes IVIG 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes Infliximab 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes Natalizumab
  • UPHP Med Pharmacy PA Criteria J0129 Orencia 
  • UPHP Med Pharmacy PA Criteria J0585 Botox 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes SCIG
  • UPHP Med Pharmacy PA Criteria J0586 Dysport
  • UPHP Med Pharmacy PA Criteria J2357 Xolair
  • UPHP Med Pharmacy PA Criteria Multiple J Codes Pegfilgrastim
  • UPHP Med Pharmacy PA Criteria J3241 Tepezza
  • UPHP Med Pharmacy PA Criteria J3380 Entyvio
  • UPHP Med Pharmacy PA Criteria J2507 Krystexxa
  • UPHP Med Pharmacy PA Criteria J2350 Ocrevus