Currentpriority healthPolicy H8379_100010852600_C (ID 26328, Version 15)

Machine-readable formulary

This document is the Priority Medicare Dual Premier 2026 List of Covered Drugs (formulary) and explains which drugs are covered, applicable rules (prior authorization, quantity limits, step therapy), cost-sharing tiers, member protections (transition fills, exceptions), and contains the beginning of the drug listing (Analgesics, NSAIDs, Opioids) with tier and limit annotations for many products. This extraction covers only Part 1 of 14.

Policy Summary

Payerpriority health

PolicyMachine-readable formulary

Policy CodePolicy H8379_100010852600_C (ID 26328, Version 15)

Change TypeUpdated (formulary update)

Effective Date

Next Review Date

Key ActionIf a drug's 'Necessary actions' column lists PA, the prescriber must obtain prior authorization from the plan before the drug will be covered; failure to obtain PA may result in noncoverage.

SourceLink

POLICY UPDATE CHANGES

Formulary was updated on 5/21/2026.

This Drug List was updated on 5/21/2026.

15Formulary Version

30Default transition supply days

5/21/2026Last updated

manyRequire Prior Authorization (PA)

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multipleHave Quantity Limits (QL)

someHave Limited Access (LA)

Coverage Summary & Scope

General Coverage Conditions

Covered when ALL of the following are met:

ALL of the following

The requested drug appears on Priority Medicare Dual Premier's List of Covered Drugs (the Drug List) for the member's plan or an approved exception has been granted.
A licensed prescriber has prescribed the drug for a medically accepted indication and documentation supports medical necessity.
The prescription is filled at a Priority Medicare Dual Premier network pharmacy or via an approved network arrangement for specialty/medical benefit drugs.
Any required prior authorization (PA), step therapy (ST), or quantity limit (QL) conditions listed for the specific drug or drug class have been satisfied.
For drugs requiring clinical criteria (e.g., diagnosis, lab values, prior therapies), the member's medical record or prescriber attestation verifies the required criteria are met as described in the Drug List entry notes.
Coverage is subject to the plan's formulary tier and associated member cost-share; availability is subject to applicable federal/state program rules (Medicare and Michigan Medicaid) and the plan's utilization management controls.

Circumstances Requiring Prior Actions or Limits

Coverage is subject to the following utilization controls and prior actions (these must be satisfied before coverage is approved):

ALL of the following

Prior Authorization: PA is required when the Drug List indicates 'Prior Authorization' for the drug or drug class. Prescribers must submit supporting clinical documentation as specified in the drug entry; lack of required documentation may result in denial.
See per-drug entry for required clinical fields (diagnosis codes, prior therapies, lab thresholds).
Step Therapy: Step therapy (ST) applies when the Drug List indicates 'Step Therapy' — the member must try and fail or have intolerance/contraindication to specified preferred agents before the requested drug will be covered.
Step exceptions can be requested if the member has a documented history of adverse reaction, contraindication, or clinical inappropriateness for the required step agents.
Quantity Limits: Quantity limits (QL) apply when the Drug List specifies a maximum quantity or days' supply per fill or per time period. Requests exceeding the QL require justification and PA.

Formulary Change Protections / Transition Fills

Formulary change protections and member transition fills:

ALL of the following

If a member is actively taking a drug that was on the Drug List at the start of the plan year, the plan will generally not remove coverage or add new restrictions for that drug during the remainder of the year unless required by safety concerns, market withdrawal, or therapeutically equivalent substitutions (e.g., new generic or biosimilar).
New enrollees or members affected by a formulary change may be eligible for temporary transition supplies to allow completion of therapy while PA or exception requests are processed. Transition fills are limited in duration as defined by plan policy and are intended to provide short-term access only.
When the plan replaces a drug with a therapeutically equivalent agent (including generic or biosimilar substitutions), the new agent will be placed on the same or lower cost-sharing tier and with equal or fewer restrictions when possible. Members will be notified of specific changes and any available transition support.
For market withdrawals or safety-based removals, the plan will provide clinically appropriate transition assistance and member notification with instructions for alternative therapies and coverage pathways.

Exception / Appeal Timelines

Timelines for exception and appeal decisions:

ALL of the following

Standard exception decision: the plan will make a decision within 72 hours (3 business days) of receiving a complete request for a drug coverage exception or prior authorization, unless federal/state rules specify a different timeframe.
Expedited (urgent) exception decision: for requests where standard timelines could seriously jeopardize the member's health, the plan will adjudicate within 24 hours of receiving the request; if more information is needed, the plan may extend by up to an additional 24 hours if the member or provider requests and documents the need for extension or the plan justifies the need for additional information.
Members and providers will be notified of denials and appeal rights in writing and by phone per Medicare/Michigan Medicaid communication requirements, including instructions to request reconsideration or file an appeal; timelines for appeals follow program regulations and are detailed in member materials.

This document is Priority Medicare Dual Premier's 2026 List of Covered Drugs (Part 1). Coverage of drugs listed is subject to the formulary tiers, utilization management controls (including prior authorization, step therapy, and quantity limits), and other restrictions described in this Drug List and applicable Medicare and Michigan Medicaid rules.

Formulary Entries — Utilization Controls & Limits

Formulary entries with utilization controls

Each drug entry lists tier/cost share and required utilization controls. Coverage is subject to the listed controls.

Formulary drug list (sample leaves)

EMGALITY — PA; QL 2 mL per 30 days (300 mg dose QL 3 mL per 30 days); Tier 3QL 2 mL per 30 days
PA indicated on formulary
NURTEC — PA; QL 18 EA per 30 days; Tier 3QL 18 EA per 30 days
PA indicated on formulary
Diclofenac sodium external solution: diclofenac sodium external solution 1.5% — QL 750 ML per 30 days; Tier 4

Provider Actions & Operational Requirements

Prior Authorization

Prior authorization required when noted (PA)

If a drug's listing shows PA (Prior Authorization), the prescriber must obtain prior authorization from the plan before the drug will be covered; failure to obtain PA may result in noncoverage. Examples of products requiring PA include migraine and specialty agents such as EMGALITY (PA; QL 2 mL per 30 days, 300 mg dose QL 3 mL per 30 days), NURTEC (PA; QL 18 EA per 30 days), and many oncology / molecular-targeted agents listed with PA (for example TABRECTA, TAFINLAR, TAGRISSO and others).

Prescriber must obtain PA when 'PA' is indicated on the drug line.
Failure to obtain PA may lead to noncoverage.
Examples: EMGALITY, NURTEC, many oncology agents (TABRECTA, TAFINLAR, TAGRISSO).

Documentation Required

Exception request supporting statement

Prescribers must submit a supporting statement for exception requests by phone, fax, or mail. Fax: 877.974.4411. Mail: Priority Health Medicare, MS 1260, 1231 East Beltline Ave, NE Grand Rapids, MI 49525. After the plan receives the prescriber's supporting statement, a standard exception decision is provided within 72 hours; expedited requests with prescriber support are decided within 24 hours.

Drug Listings & Code Groups

Definitions & Legend

Formulary legend — key codes used in the ‘Necessary actions, restrictions, or limits on use’ column: PA = Prior Authorization required; QL = Quantity Limit (exact units/time shown per product); ST = Step Therapy required; MC = Medicaid‑covered or medical channel/Member Cost $0; HI = Home Infusion/high‑intensity handling; LA = Limited Access (available only at certain pharmacies); B/D = Part B vs Part D / billing designation; NE = Not available via Express Scripts/Home Delivery. Tiers indicate member cost‑sharing: Tier 1/2 = $0; Tier 3/4/5 = 25% coinsurance (after $615 deductible for applicable tiers).

Background & Scope Notes

Background: This file is Part 1 of the Priority Medicare Dual Premier 2026 List of Covered Drugs (formulary) for the HMO D‑SNP plan (Version 15, last updated 5/21/2026). It includes index entries, tier designations, member cost‑share indicators, and examples of utilization controls; it represents the start of a multi‑part extraction (Part 1 of 14).

Key thresholds and examples

Deductible threshold$615 deductible for Tier 3-5 (coinsurance applies after deductible)

Default transition supply30 days (temporary supply for new members during first 90 days; long‑term care residents may receive one 31‑day supply after first 90 days)

Example QL pattern — topical/volumeSome products list ML/GM limits (e.g., diclofenac sodium external solution QL = 750 ML per 30 days; tacrolimus external ointment QL = 100 GM per 30 days)

Example QL pattern — count per periodMany products list EA limits (e.g., fentanyl transdermal QL = 10 EA per 30 days; tramadol ER QL = 30 EA per 30 days)

Note on QL variability

Quick FAQ

Q: How do I find drugs on the Drug List? A: Search alphabetically in the Index of Covered Drugs (Section D) or by medical condition in Section C1.

Q: How long to get exception decisions? A: Standard exception decisions are made within 72 hours after receiving the prescriber’s supporting statement; expedited requests with prescriber support are decided within 24 hours.

Revision History

2026-05-21formulary_updateLatest

Formulary was updated on 5/21/2026. (Version 15)

2026-05-21non_material_changeLatest

Header indicates last update date; no clinical policy statement change is indicated in this part.

2026-05-21non_material_change

Policy Summary

Payerpriority health

PolicyMachine-readable formulary

Policy CodePolicy H8379_100010852600_C (ID 26328, Version 15)

Change TypeUpdated (formulary update)

Effective Date

Next Review Date

SourceLink

On This Page

Specialty or Medical-Benefit Drugs: Drugs designated as specialty or billed under the medical benefit may have separate network, dispensing, or site-of-care requirements and may require PA and additional documentation (e.g., prior infusion records).

Pharmacies and providers should follow billing instructions and include HCPCS/NDC and infusion visit documentation when applicable.

Transitions and Protection: Members newly enrolled or transitioning therapies may be eligible for temporary transition fills per the plan's transition policy (see Transition Protections group).

Quantity limit shown in formulary

Fentanyl transdermal: fentanyl transdermal patch 72 hour — QL 10 EA per 30 days; Tier 410 EA per 30 days

QL shown in formulary

Methadone solutions/tablets: methadone HCl oral solution 10 mg/5 ml — QL 600 ML per 30 days; methadone 5 mg/5 ml — QL 1200 ML per 30 days; methadone tablets have QLs (90/120 EA) as listed; Tier 4varies per formulation

QL values captured per product

Opioid QLs: Multiple opioid short- and long-acting products list specific QLs (e.g., tramadol ER QL 30 EA per 30 days) and tiers as shown in formularyproduct-specific QLs

See drug lines for exact QL values

XIFAXAN 200 mg — PA; QL 9 EA per 30 days; XIFAXAN 550 mg — PA; QL 60 EA per 30 days; Tier 4/5 as listedproduct-specific QL

PA and QL shown on formulary

Brivaracetam/EPIDIOLEX/FINTEPLA: Brivaracetam — PA; QL (600 ML per 30 days solution / 60 EA per 30 days tablet); EPIDIOLEX — PA; QL 500 ML per 30 days; FINTEPLA — PA; QL 360 ML per 30 days; Tier 5 where notedproduct-specific QLs

Formulary shows PA and QL

Formulary drug coverage actions and limits

Each drug entry lists tier, and necessary actions/restrictions/limits on use when present.

Oncology / specialty examples

TABRECTA — PA; QL 120 EA per 30 days; Tier 5 (25%)QL 120 EA per 30 days
PA and QL shown in formulary
TAFINLAR / TAFINLAR soluble: TAFINLAR — PA; QL 120 EA per 30 days; TAFINLAR soluble — PA; QL 840 EA per 28 days; Tier 5product-specific QLs
Formulary lists PA and QL
TAGRISSO — PA; LA; QL 30 EA per 30 days; Tier 5QL 30 EA per 30 days
LA flag and PA indicated
VENCLEXTA / VERZENIO / VITRAKVI: VENCLEXTA (some strengths) — PA; VERZENIO — PA; QL 60 EA per 30 days; VITRAKVI — PA; QL values per strength (e.g., 60 EA / 90 EA / 300 ML); Tier as listedproduct-specific QLs
PA and QL shown
XALKORI / XOSPATA: XALKORI (capsule & sprinkle forms) — PA; LA; QL values per presentation (e.g., 120–180 EA per 30 days); XOSPATA — PA; QL 90 EA per 30 daysproduct-specific QLs
PA and LA flags present

Formulary entries and utilization controls

Each drug entry includes tier/cost and any necessary actions/restrictions/limits on use as listed below:

HIV / antiviral per-drug controls

Emtricitabine-TDF / TAF entries: emtricitabine-tenofovir DF tablets — Tier 5; QL 30 EA per 30 days; emtricitabine-tenofovir DF 200-300 mg — Tier 4; QL 30 EA per 30 daysQL 30 EA per 30 days
Per-product tier and QL listed in formulary
VIREAD oral powder — Tier 5; QL 240 GM per 30 days; VIREAD oral tablet — Tier 5; QL 30 EA per 30 daysQL per formulation
Formulary shows powder/tablet QLs
JULUCA / ODEFSEY / TIVICAY: JULUCA and ODEFSEY — Tier 5; QL 30 EA per 30 days; TIVICAY 50 mg — QL 60 EA per 30 days; many HIV combos list QL 30 EA per 30 daysQL 30–60 EA per 30 days
Per-drug QLs shown in formulary
Maraviroc / SELZENTRY / RUKOBIA: maraviroc tablets — QL values listed (e.g., 60/120 EA per 30 days); SELZENTRY solution QL 1800 ML per 30 days; RUKOBIA QL 60 EA per 30 daysproduct-specific QLs
Formulary captures QLs per product

Fax supporting statement to 877.974.4411.
Mail to Priority Health Medicare, MS 1260, 1231 East Beltline Ave, NE Grand Rapids, MI 49525.
Standard decision: within 72 hours of receiving prescriber statement.
Expedited decision: within 24 hours with prescriber support when delay may cause harm.

Billing Rule

Network pharmacy requirement and tiered cost share

Prescriptions must be filled at an in‑network pharmacy to be covered. Member cost sharing follows the formulary tier: many drugs are $0 for Tier 1/2 or MC, while Tier 3–5 drugs carry 25% coinsurance after the $615 deductible. Claims must conform to the drug's listed utilization controls (QL/PA/ST/HI) on the formulary entry for coverage.

Fill at a Priority Medicare Dual Premier network pharmacy for coverage.
Tier cost-share examples: $0 (Tier 1/2 or MC) vs 25% (Tier 3–5) with $615 deductible for higher tiers.
Claims/adjudication must match listed QL/PA/ST/HI on the drug line.

Step Therapy

Step therapy required for selected products

Step therapy (ST) is required for certain drugs — the member must try specified preferred agents before the nonpreferred drug will be covered. Examples in the formulary include FETZIMA (ST; QL 30 EA per 30 days), TRINTELLIX (ST; QL 30 EA per 30 days), and eletriptan hydrobromide (ST; QL 6 EA per 30 days). Follow the plan's step-therapy procedures when ST is indicated on the drug line.

Step therapy applies where 'ST' is shown on the drug entry.
Examples: FETZIMA, TRINTELLIX, eletriptan hydrobromide.
Adhere to the plan's ST procedures to obtain coverage.

Documentation Required

Special handling flags (LA, B/D, HI) — see full formulary

Some products are flagged for special handling: LA (Limited Access), B/D (billing/benefit designation), and HI (home infusion/high-intensity). These flags indicate special distribution, coverage channel, or operational billing procedures. Providers should consult the full formulary pages for each product (the formulary lists LA, B/D, HI on drug lines) and follow the plan's operational billing instructions.

LA = Limited Access (may be available only at certain pharmacies).
B/D = special billing/benefit designation (may affect Part B vs Part D adjudication).
HI = home infusion or high-intensity handling for certain IV/injectable products.
Consult the full formulary drug page for operational billing and coverage rules.

Billing Rule

Quantity limits enforced at adjudication (QL values shown per period)

Quantity limits (QL) are enforced at claim adjudication and are specified per product as EA/ML/GM over a defined period. Providers and pharmacies must ensure dispensed quantities match the listed QL to avoid denial or requirement for PA. Examples of QLs in the formulary include diclofenac sodium external solution QL = 750 ML per 30 days, fentanyl transdermal QL = 10 EA per 30 days, methadone oral solution QL = 600 ML per 30 days (and 1200 ML per 30 days for other strength entries), tramadol ER QL = 30 EA per 30 days.

QL units are expressed as EA (each), ML (milliliters), or GM (grams) per period.
Examples: 750 ML/30 days (diclofenac external), 10 EA/30 days (fentanyl transdermal), 600 ML/30 days (methadone solution), 30 EA/30 days (tramadol ER).
Claims exceeding listed QL may require prior authorization or be denied.

Quantity limits vary by product and formulation — exact QL values are specified on each drug line (examples shown above are from specific product entries)

Version 15 of the formulary; part contains index entries and language assistance notices.