Priority Partners Prior (Rx) Authorization Form

Updated December 07, 2022

Priority Partners prior authorization form allows a medical professional to request coverage for a medication that isn’t under the medical plan’s formulary. This is specifically for patients who are Priority Partners members through the John Hopkins Medicine LLC. The completed form can be submitted for review by sending it to one of the fax numbers provided below.

How to Write

Step 1 – Begin by entering the patient’s full name, member ID number, date of birth, gender, and select their relationship into the Member Info section.

Step 2 – In Provider Info, enter the provider’s full name, their NPI number, an office contact name, their office telephone number, and their office fax number.

Step 3 – In Medication Requested, you must enter the drug name, strength, dosage and frequency, and the duration of therapy. Next, you must list what tests and trials have been performed to determine the relevant diagnosis for this patient.

Step 4 – In Previous Formulary Trial(s), you must enter the name, strength, dosage, duration of trial, and the treatment outcome of any previous medications that have been used to treat this diagnosis.

Step 5 – Finally, you must provide your signature and the date where indicated.