Get Priority Health Pharmacy Prior Authorization Form 2024-2025

Filling out the Priority Health Pharmacy Prior Authorization Form online can be a straightforward process. This guide provides clear, step-by-step instructions to help you effectively complete the form, ensuring all necessary information is accurately provided.

Follow the steps to complete the form easily.

1. Click the ‘Get Form’ button to access and open the Priority Health Pharmacy Prior Authorization Form in your preferred editing software.
2. Enter the patient’s last name, first name, member ID number, date of birth, and gender in the designated fields. Ensure that all information is accurate and legible.
3. Input the provider's phone number and fax number. Then, fill in the primary care physician's name, the requesting provider's name, their address, and their national provider identifier (NPI) number.
4. Provide the contact person’s name and complete the provider's signature and date fields, ensuring these sections are signed by the requesting provider.
5. In the 'Product Information' section, specify the medication requested along with the start date or date of the next dose, strength, the date of the last dose if applicable, dosing frequency, and the anticipated length of therapy.
6. Complete the Priority Health Precertification Documentation by describing the patient's medical condition related to the requested drug and the medical justification for this request.
7. List any previous medications the patient has tried, including the drug name, strength, dosing schedule, date prescribed, and date stopped for each medication.
8. Attach any additional documentation that supports the request. This could include chart notes or lab records, which can help in the approval process.
9. Review all information for completeness and legibility, ensuring every field has been correctly filled out before proceeding.
10. Once satisfied with the completed form, proceed to save your changes. You can also choose to download, print, or share the form as needed.

Start filling out the Priority Health Pharmacy Prior Authorization Form online today to ensure timely processing of your request.