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Pharmacy Prior Authorization Form

Drugs that are not listed in the formulary must be approved by your doctor before they can be filled at the pharmacy. In order for your doctor to request that Priority Partners cover a medication for you, print this form and take to your PCP to fill out and submit.

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Priority Partners members whose medical care is impacted by the recent collapse of the Francis Scott Key Bridge are encouraged to call our Customer Service team for assistance at 800-654-9728.
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