Pharmacy Prior Authorization Form
This document is the prior authorization form used by Priority Health for commercial members to request pharmacy coverage of medications; it governs providers submitting PA requests and specifies required information and supporting documentation.
No material clinical or coverage changes in this revision.
Coverage Criteria
Requests for use of a medication in an indication, dose, or route of administration that is not FDA‑approved or not listed in CMS‑accepted compendia require supporting evidence. Specifically, the form states that such off‑label requests must be accompanied by two published peer‑reviewed literature articles that support the appropriateness of the drug, the dosing, or the route of administration for the requested indication. Absence of the required supporting literature may result in denial of coverage.
Provider Actions and Submission Requirements
Prior Authorization Required
Prior authorization is required. Submit a completed Pharmacy Prior Authorization Form (fax: 877.974.4411 toll free or 616.942.8206). Indicate whether the request is urgent (life‑threatening) or non‑urgent (standard review).
- Applicable to Commercial (Traditional) and Commercial (Individual/Optimized)
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