Pharmacy Prior Authorization Form - Coverage Criteria
Form and instructions to request prior authorization for pharmacy medications for Priority Health commercial members; it governs providers submitting PA requests and the documentation required.
No material clinical or coverage changes in this revision.
Coverage Criteria
Submission and evidence criteria
Covered when ALL of the following submission requirements are met:
Form fields listed in chunks 1 and 2
See chunk 3
See chunk 2
The form does not list explicit exclusions by name. However, there is an implicit limitation for requests that propose uses, dosing, or routes not FDA‑approved or not recognized in CMS‑accepted compendia: such off‑label requests must include supporting evidence and, absent that evidence, may not be supported. Specifically, the form requires two published peer‑reviewed articles when the indication, dosing, or route is not FDA‑approved or not present in CMS‑accepted compendia.
The form itself does not define additional criteria for coverage beyond the submission and evidence requirements; it provides fields to document the medication, dosing, clinical rationale, and prior therapy but does not enumerate separate ‘‘not medically necessary’’ conditions or explicit exclusion lists on the form.
Provider Submission Requirements & Actions
Prior Authorization Required
Prior authorization required. Fax completed form to: 877.974.4411 toll free, or 616.942.8206 to initiate standard or urgent review. Indicate if request is Urgent (life threatening) or Non‑Urgent (standard review). Urgent means the standard review time may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function.
- Applicable lines of business: Commercial (Traditional); Commercial (Individual/Optimized)
- Indicate request type: Urgent or Non‑Urgent
Required Submission Fields & Supporting Materials
Provide complete member and provider details with the submission to avoid processing delays.
- Member: Last name, First name, ID #, DOB, Gender assigned at birth
- Provider: Primary Care Physician, Requesting Provider, Provider phone, Provider fax, Provider address, Provider NPI, Contact name, Provider signature, Date
- Medication/therapy details: Medication requested, Start date (or date of next dose), Strength, Date of last dose (if applicable), Dosing frequency, Anticipated length of therapy
- Attach supporting materials as applicable: chart notes, lab records, prior authorization forms, and any other documentation that substantiates medical necessity
Prior Drug Trial Documentation
List prior drug therapy trials in detail. Include drug name, strength, dosing schedule/frequency, date prescribed, and date stopped. Explain the medical reason for the request and the patient’s condition for which the drug is being requested. Provide any additional documentation (chart notes, lab records) to support the request.
- A. Patient's medical condition for which the drug is requested
- B. Medical rationale for this request
- C. Prior drugs tried: include Drug name; Strength; Dosing schedule/frequency; Date prescribed; Date stopped; any other relevant information
- D. Additional documentation: chart notes, laboratory records, and other supporting evidence
Off‑label / Compendia Unsupported Use Documentation
For off‑label uses or indications not supported by CMS‑accepted compendia, provide clinical evidence: two published peer‑reviewed articles that support the appropriateness of the drug, the dosing, or the route of administration for the requested indication.
- Off‑label/Compendia unsupported use requires two published peer‑reviewed literature articles
- Compendia examples: DrugDex, AHFS, U.S. Pharmacopeia (and Clinical Pharmacology for oncology indications only)
Background
This form collects clinical and administrative information to evaluate medical necessity for pharmacy benefits. It requests the medication name, start date or next dose, strength, dosing frequency, anticipated length of therapy, and date of last dose (if applicable), and it instructs providers to supply supporting evidence when the request is for an off‑label or compendia‑unsupported use (including two published peer‑reviewed articles in those cases).
Definitions
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