Currentpriority healthPolicy N/A

Chronic Condition Drug Coverage List

Lists covered drugs and diabetes supplies for Priority Health employer group and individual HSA plans with a chronic condition rider; informs providers and members about formulary coverage, generic preference, and that prior authorization/step therapy may apply.

Policy Summary

Payerpriority health

PolicyChronic Condition Drug Coverage List

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionCheck the Approved Drug List for prior authorization and step therapy requirements before prescribing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug classes listed

extensivediabetes products included

may applyPA/step therapy

requiredgeneric-first policy

Coverage Criteria Summary

This list highlights drugs and diabetes supplies that may be covered under Priority Health employer group and individual HSA plans with a chronic condition rider, but it is not a complete list of covered medications. Some drugs and products may be excluded under a member’s specific plan. Always verify coverage details, including any exclusions, in the member’s plan documents and the Approved Drug List before prescribing or billing.

Policy Summary

Payerpriority health

PolicyChronic Condition Drug Coverage List

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionCheck the Approved Drug List for prior authorization and step therapy requirements before prescribing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain medications. Check the plan-specific Approved Drug List (formulary) to determine whether a prior authorization (PA) is needed before prescribing.

Verify PA requirements on the Approved Drug List/ formulary before prescribing.
Failure to obtain required PA may result in claim denial or member financial responsibility.

Step Therapy

Step Therapy May Be Required

Step therapy may apply to some drugs. Confirm any step therapy protocols on the Approved Drug List and ensure required prior steps are met before prescribing alternative agents.

Review step therapy requirements on the Approved Drug List prior to initiating therapy.
Not following step therapy may lead to denial or increased member cost sharing.

Note

Formulary Reference for Supplies

Insulin needles, syringes and related diabetes supplies are listed on the Approved Drug List (formulary). Refer to the formulary for coverage details and any applicable limits or preferred products.

Covered diabetes supplies include insulin needles, insulin syringes, lancets and pen needles — see Approved Drug List for specifics.
Formulary may list brand and generic options; check for preferred products and quantity limits.

Denial Risk

Prior Authorization / Step Therapy Risk

If prior authorization or step therapy requirements are not followed, claims may be denied and members may be financially responsible for the medication or supply costs. Always verify PA and step therapy status before prescribing or dispensing.

Noncompliance with PA/step therapy can result in denial and increased member cost sharing.
Confirm requirements via the Approved Drug List or payer PA portal to avoid delays and denials.

Billing Rule

Generic Substitution Requirement

Priority Health requires use of a generic when available. Choosing a brand product when a generic equivalent exists may increase the member's cost sharing or create a point-of-sale responsibility.

Select generic alternatives when clinically appropriate to minimize member cost sharing.
Document medical justification if a brand-name product is necessary.

Background

This document provides the coverage list for chronic condition drugs and related diabetes supplies for Priority Health employer group and individual HSA plans that include the chronic condition rider. It groups covered products by therapeutic area (for example, diabetes supplies and osteoporosis agents) and indicates product-level coverage on the Approved Drug List. Providers should note that prior authorization and step therapy may apply to certain medications and that Priority Health has a generic-first requirement when a generic is available; check the member’s plan documents and the Approved Drug List for PA/step therapy requirements and exact product coverage before initiating therapy.

Step therapy requirement	Notes
Step therapy may be required for certain medications
Verify specific step requirements on the Approved Drug List; requirements may vary by medication and plan

OpenPayer

Chronic Condition Drug Coverage List

Coverage Criteria Summary

Provider Actions & Authorization Requirements

Background

Definitions

Step Therapy Details