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Priority Health Medicare Employer Group Formulary (Drug List) — Coverage Criteria

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Defines the covered prescription drugs, formulary structure, restrictions (prior authorization, quantity limits, step therapy), and exception/transition processes for Priority Health Medicare Employer Group members.

Policy Summary

Payerpriority health

PolicyPriority Health Medicare Employer Group Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJune 1, 2026

Last ReviewMay 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug entry lists 'PA' before dispensing to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6/1/26formulary current as of

v15document version

30 daystransition supply

72 hrsstandard exception time

24 hrsexpedited exception

30-dayTier 5 supply limit

Coverage Criteria and Formulary Rules

General formulary coverage

Covered when ALL of the following general conditions are met:

General coverage conditions: Drug is listed on the Priority Health Medicare formulary, is medically necessary, is dispensed at a Priority Health Medicare network pharmacy, and other plan rules (e.g., PA, QL, ST, B/D, HI, LA) are followed.

See formulary listings and Requirements/Limits for product-specific controls.

Transition and emergency supply

Temporary coverage provisions:

Transition supply: Members taking non-formulary or restricted drugs will be provided a temporary 30-day supply (31 days for long-term care residents) while pursuing a formulary exception or transition, unless the prescription is written for fewer days.30 days

Standard temporary transition supply; see long-term care exception (31 days).

New member transition: For each drug not on formulary or with a restriction, Priority Health Medicare may cover a temporary 30-day supply during the first 90 days of membership while a coverage decision or exception is pursued.30 days

Coverage ends after temporary supply if exception not approved.

Level-of-care change: Members experiencing a level-of-care change will be provided a transition supply of at least 30 days of medication unless the prescription is written for fewer days.30 days

Applies when site-of-care or care-level changes occur.

General coverage rule for listed formulary products

Covered when product is on formulary subject to noted prior authorization and quantity limits:

Formulary coverage rule: Drug is covered according to its assigned formulary tier (T1–T6). Where Prior Authorization (PA) is indicated in the Requirements/Limits column, PA must be obtained prior to coverage. Where a Quantity Limit (QL) is specified, covered supply is limited to the stated amount per time period.see QL per product

B/D indicates Part B vs Part D billing; Tier 5 specialty drugs limited to 30-day supply.

Formulary tier and restriction rules

Coverage is determined by formulary tier with specific quantity limits and prior authorization requirements applied where noted.

Tier-based coverage: Drugs are assigned to formulary tiers (T1–T6); coverage, cost-sharing, and supply rules follow the tier assignment. Tier 5 (Specialty) drugs are limited to a 30-day supply unless otherwise specified.

Refer to tier legend for definitions.

Prior authorization and quantity limits: If a product's Requirements/Limits field lists PA, prior authorization is required before coverage. If QL is listed, the allowed amount is restricted to the stated QL (e.g., TRULICITY PA; QL 2 mL per 28 days; ENTRESTO QL 240 EA per 30 days).see product QL

Providers must submit documentation to support PA and requested QL.

Formulary coverage with tier and requirement flags

Coverage and access are governed by tier assignment plus any listed requirement/limit flags. Examples below reflect how the document structures coverage rules for select product groups.

Vaccine and select injectables: Coverage of vaccines and select injectable products is subject to tier assignment and any explicit quantity limits (QL) or Part B/Part D designation (B/D). Specific vaccines list QL values where applicable (e.g., ACTHIB QL 1 EA per 365 days; MRESVIA QL 0.5 mL per 720 days; SHINGRIX QL 1 mL per 999 days).see code groups

Providers must follow PA/QL/B-D billing instructions where flagged.

Specialty injectables and bone agents: Certain specialty injectables and metabolic bone disease agents are assigned PA and QL requirements (e.g., EVENITY PA; QL 2.34 mL per 30 days; TERIPARATIDE PA; QL per product).see product QLs

PA must be obtained per formulary before coverage is approved.

Prior authorization required

Specialty and high-cost products:

PA-required specialty agents: Certain specialty agents require prior authorization (PA) and often have quantity limits; examples include EVENITY, TERIPARATIDE, TYMLOS, YORVIPATH, CYSTADROPS, CYSTARAN, and OXERVATE.see code groups

PA must be obtained per formulary before coverage is approved.

PA and QL enforcement: Failure to obtain required prior authorization or exceeding listed quantity limits may result in claim denial or non-coverage for specialty/high-cost drugs.

Providers should submit required documentation per PA process.

Step therapy requirements

Step therapy and utilization management for ophthalmics:

Ophthalmic step therapy: Selected ophthalmic anti-inflammatories and prostaglandin/prostamide products are subject to Step Therapy (ST) where indicated (entries flagged 'ST' such as travoprost, difluprednate, loteprednol).N/A

Follow ST protocol and document prior therapeutic trials when requesting authorization.

Coverage with utilization controls

Formulary coverage and utilization controls — drugs are categorized by tier and may have QL, PA, LA, B/D or other restrictions:

Formulary assignment: Drugs are assigned formulary tiers (T1–T6); tier determines cost-sharing and supply rules (e.g., Tier 5 = 30-day supply).

See tier legend for definitions and supply rules.

Utilization controls: If a drug row lists PA, LA, QL, ST, or B/D it is subject to that requirement (e.g., INCRUSE ELLIPTA QL 30 EA per 30 days; SPIRIVA RESPIMAT QL 4 GM per 30 days; TRIKAFTA PA; QL 84 EA per 28 days).

Claims must meet listed PA and QL rules to be covered; LA and B/D affect availability and benefit routing.

Drugs labeled ED (Excluded Drug) in this formulary are not normally covered under a Medicare Prescription Drug Plan. The formulary defines ED as a category where the prescription is not ordinarily payable by the Part D benefit, and amounts paid by the enrollee for ED drugs do not count toward total drug costs (they do not help the member reach catastrophic coverage) and recipients of extra help will not receive assistance for ED drugs.

The formulary legend defines ED = Excluded Drug and explains the implications for billing and benefit calculations. Specifically, ED drugs are not normally covered by the Medicare Part D benefit and payments for ED drugs are excluded from measures such as progress toward catastrophic coverage. Providers and billing staff should treat ED-marked items as outside the plan's Part D coverage unless alternative coverage (e.g., Part B or a medical benefit) is documented and allowable.

Within the extract provided there are no broad clinical exclusions that remove whole therapeutic classes from coverage; instead the document uses utilization controls (for example, PA, QL, ST, B/D, HI, LA) and the ED flag for specific products. This means most coverage decisions in the excerpt are implemented through prior authorization, quantity limits, step therapy, or benefit routing rather than blanket clinical exclusions.

The extract's formulary legend includes the ED abbreviation but does not list a comprehensive excluded-drug section in these chunks; rather, ED appears as a requirements/limits flag on individual rows. Reviewers should consult the product rows and the legend together to identify which specific entries are flagged ED.

Examples of products in the extract that are flagged ED include several topical and dermatologic preparations. The listing shows entries such as RENOVA and RENOVA PUMP marked ED, salicylic acid external lotion marked ED, and multiple urea external products (cream/gel) listed with Requirements/Limits = ED.

The formulary explicitly notes that rows with Requirements/Limits = ED are not covered under the Part D formulary. For example, RENOVA and certain urea topical products show ED in their requirements/limits designation, indicating exclusion from coverage.

Additional specific products marked ED in the extract include selected genitourinary and reproductive therapy items. The listing shows phenazopyridine HCl (100 mg, 200 mg) and several fertility-related agents (e.g., cetrorelix / CETROTIDE) with Requirements/Limits = ED, indicating these items are excluded from Part D coverage in the displayed segment.

The document identifies infertility and reproductive therapy products among those annotated ED. For example, CETROTIDE SUBCUTANEOUS KIT 0.25 MG and related entries are shown with Requirements/Limits = ED, denoting exclusion in this formulary extract.

Some index rows display the ED flag in respiratory and other sections. For example, the respiratory segment shows benzonatate with an ED designation on the index row in this extract, demonstrating that ED annotations can appear at the row/index level for a range of agents.

Abbreviations, Codes and Quantity Examples

Abbreviationsmixed

B/D	Part B vs. Part D - drug may require prior authorization and may be covered differently under Medicare Part B (medical) or Part D (prescription) depending on circumstances.
EA	Each
ED	Excluded Drug - not normally covered in a Medicare Prescription Drug Plan; cost does not count toward total drug costs for catastrophic coverage; extra help not available for this drug.
HI	Home Infusion
LA	Limited Availability
NE	No Express Scripts
PA	Prior Authorization
QL	Quantity Limits
ST	Step Therapy
ML	Milliliters

1–10 of 11

1/2

Common Abbreviations (continued)mixed

T1	Preferred generic
T2	Generic
T3	Preferred brand
T4	Non-preferred drug
T5	Specialty
T6	Infertility

Selected Formulary Products with Quantity Limits (Examples)NDC

ARIKAYCE	QL example: 235.2 ML per 28 days (illustrative)
LIDOCAINE_PATCHES	QL example: 90 EA per 30 days
FENTANYL_PATCH	QL example: 10 EA per 30 days
XIFAXAN_200MG	PA; QL 9 EA per 30 days
XIFAXAN_550MG	PA; QL 60 EA per 30 days
VANCOMYCIN_ORAL_CAPSULE_125MG	QL 80 EA per 30 days (125 mg)
VANCOMYCIN_ORAL_CAPSULE_250MG	QL 160 EA per 30 days (250 mg)

Formulary Entries with PA/QLNDCCovered

XIFAXAN_200MG	PA; QL (9 EA per 30 days)
XIFAXAN_550MG	PA; QL (60 EA per 30 days)

Vancomycin FormulationsNDCCovered

VANCOMYCIN_IV_RECONSTITUTED_1GM	Home Infusion (HI) for IV reconstituted 1 gm; tier varies
VANCOMYCIN_ORAL_CAPSULE_125MG	Oral capsule 125 mg; QL 80 EA per 30 days
VANCOMYCIN_ORAL_CAPSULE_250MG	Oral capsule 250 mg; QL 160 EA per 30 days

Anticonvulsants / Specialty AgentsNDCCovered

BRIVARACETAM	PA; QL examples (oral solution/tablet)
EPIDIOLEX	PA; QL (500 ML per 30 days)
FINTEPLA	PA; QL (360 ML per 30 days)
XCOPRI	PA; QL (varies by strength)

Placeholder - No CPT/HCPCS/ICD codes in excerptmixed

No codes listed

Drugs with Specified Strengths (examples)NDC

TRULICITY_AUTOINJECTOR	PA; QL (2 ML per 28 days)
XARELTO_10MG	QL (30 EA per 30 days)
XARELTO_15MG	QL (60 EA per 30 days)
ENOXAPARIN_PREFILLED_30MG	QL (18 ML per 30 days)
ENOXAPARIN_PREFILLED_40MG	QL (24 ML per 30 days)
ENOXAPARIN_PREFILLED_60MG	QL (36 ML per 30 days)
INVEGA_SUSTENNA_PREFILLED	QL examples by strength (ml per 30 days)

Formulary drug listings and limits (cardiovascular examples)NDC

CANDESARTAN_4MG	Tier 2; QL 240 EA per 30 days
CANDESARTAN_8MG	Tier 2; QL 120 EA per 30 days
CANDESARTAN_16MG	Tier 2; QL 60 EA per 30 days
CANDESARTAN_32MG	Tier 2; QL 30 EA per 30 days
IRBESARTAN_75MG	Tier 1; QL 120 EA per 30 days
IRBESARTAN_150MG	Tier 1; QL 60 EA per 30 days
IRBESARTAN_300MG	Tier 1; QL 30 EA per 30 days
LOSARTAN_25MG	Tier 1; QL 90 EA per 30 days
LOSARTAN_50MG	Tier 1; QL 60 EA per 30 days
LOSARTAN_100MG	Tier 1; QL 60 EA per 30 days

1–10 of 20

1/2

Formulary requirement codes and examplesmixed

PA	Prior Authorization required for certain products (see entry)
QL	Quantity limits specified per product and strength (see entry)
HI	Home Infusion requirement noted for some IV products
B/D	Medicare Part B vs Part D note applies for specified items
ST	Step therapy requirement applies to certain ophthalmic and dermatologic agents

Sample formulary drug entries (partial)NDC

LISINOPRIL_2.5MG	Tier 1; example strengths listed
LISINOPRIL_10MG	Tier 1; QL 120 EA per 30 days
LISINOPRIL_20MG	Tier 1; QL 60 EA per 30 days
BENAZEPRIL_5MG	Tier 1; QL 480 EA per 30 days
BENAZEPRIL_10MG	Tier 1; QL 240 EA per 30 days
BENAZEPRIL_20MG	Tier 1; QL 120 EA per 30 days
BENAZEPRIL_40MG	Tier 1; QL 60 EA per 30 days
ENALAPRIL_2.5MG	Tier 1; QL 480 EA per 30 days
ENALAPRIL_5MG	Tier 1; QL 240 EA per 30 days

Biologic / Biosimilar entriesNDC

REPATHA	PA; QL (2 ML per 28 days)
DUPIXENT_300MG_2ML	PA; QL (8 ML per 30 days)

Selected Vaccines and Quantity-Limited ProductsNDCCovered

SHINGRIX	QL (1-2 EA per long interval; see formulary)
AREXVY	QL (1 EA per 720 days)
MRESVIA	QL (0.5 ML per 720 days)
PENBRAYA	QL (2 EA per 720 days)
JYNNEOS	Requirements/Limits = B/D
IMOVAX_RABIES	Requirements/Limits = B/D

Metabolic Bone Disease / Specialty InjectablesNDCCovered

EVENITY	PA; QL (2.34 ML per 30 days)
TERIPARATIDE_PEN	PA; QL (2.48 ML per 30 days)
TYMLOS	PA; QL (1.56 ML per 30 days)
ZOLEDRONIC_ACID_IV	B/D for IV formulations

Ophthalmic agents with PA/QL/STNDCCovered

RESTASIS_MULTIDOSE_0.05%	QL (5.5 ML per 30 days)
CYSTADROPS	PA; QL (20 ML per 30 days)
OXERVATE	PA; QL (28 ML per 30 days)
LUMIGAN_0.01%	tiered
DIFFLUPREDNATE	ST (step therapy) applies

Otic and Respiratory agentsNDCCovered

CIPROFLOXACIN_DEXAMETHASONE_OTIC	QL (7.5 ML per 30 days)
ALBUTEROL_HFA	QL (17-36 GM per 30 days depending on NDC)
INCRUSE_ELLIPTA	QL (30 EA per 30 days)

Placeholder - No billing codes listedmixed

No codes listed

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Priority Health requires prior authorization (PA) for many drugs listed in the formulary. Prescribers must request and receive approval before the drug is dispensed; failure to obtain required PA may result in noncoverage or claim denial.

PA applies to many specialty, high‑cost, and selected non-specialty products across the formulary (see PA flags in drug listings).
Common PA triggers: specialty tier drugs (T5), selected oncology, immunologic, pulmonary, genetic/enzyme replacement, and other high-cost agents.
Examples of drugs requiring PA include (non‑exhaustive): XIFAXAN (200 mg and 550 mg), selected anticonvulsants (brivaracetam, EPIDIOLEX, rufinamide, etc.), DIFICID formulations, many oncology agents (e.g., VENCLEXTA, TAGRISSO), specialty biologics (e.g., DUPIXENT, REPATHA), pulmonary/cystic fibrosis products (TRIKAFTA, ORKAMBI), and multiple other PA‑flagged items throughout the formulary.

Documentation Required

Part B vs Part D — Documentation May Be Required

Some drugs are subject to a Part B vs. Part D (B/D) determination and may require additional documentation from the prescribing provider to establish the setting of use and benefit routing.

When a B/D flag appears, submit clinical documentation describing the drug’s use and administration setting to support Part B coverage when applicable.
Examples where B/D is indicated: certain infused or injectable agents and some inhalation/medical‑benefit products (see drug line entries).

Documentation Required

Quantity Limits and Documentation

Quantity limits (QL) and limited‑availability (LA) flags listed in the formulary are enforced on claims and prior authorizations. Providers must adhere to the stated QLs or request exceptions with supporting clinical justification.

Submit requested quantity and intended days’ supply on PA submissions. QLs shown in each drug row (e.g., XIFAXAN 200 mg QL = 9 EA per 30 days; XIFAXAN 550 mg QL = 60 EA per 30 days).
Tier 5 drugs are limited to 30‑day supply only unless otherwise noted.
LA (Limited Availability) items may be available only at select pharmacies — check Provider/Pharmacy Directory or contact Customer Care.

Step Therapy

Step Therapy (ST) Requirements

Step therapy (ST) requirements are used for select agents: prescribers must document prior trials of required drugs or clinical rationale for bypassing the step protocol when requesting an exception.

DIFICID oral suspension and tablets carry ST plus QL (see entries) — prescribers must document prior use/ failure of preferred therapy where applicable.
ST is referenced across multiple classes (e.g., some antidepressants, ophthalmic agents, paliperidone ER strengths) — follow the ST flag in the formulary and provide prior trial records in PA/exception requests.
If requesting an exception to ST, include the prescriber’s supporting statement explaining why the step requirement is medically inappropriate or harmful; exception decisions are generally rendered within 72 hours (24 hours for expedited requests).

Documentation Required

Prior Authorization Documentation and Timing

Prescribers must include supporting clinical documentation with PA requests: indication, prior therapy trials and dates, clinical rationale for the requested agent, relevant labs or imaging when applicable, and any B/D information needed to route the claim correctly.

Priority Health generally must make a determination within 72 hours of receiving the prescriber’s supporting statement; expedited reviews (24 hours) are available when waiting could seriously harm the member.
Documentation supports PA, QL exceptions, ST exemptions, and B/D determinations — incomplete submissions may delay or trigger denials.

Denial Risk

Denial Risk from Unmet Utilization Controls

Utilization controls — PA, QL, ST, LA, NE, B/D, and ED — can lead to claim denials when requirements are not met. Verify flags on the formulary and secure necessary authorizations before dispensing.

ED (Excluded Drug) entries are not covered and will be denied — examples include certain topical/emollient formulations and listed vitamins or pumps marked ED.
Drugs marked PA or with QL exceedances may be denied at claim adjudication without an approved authorization.
LA or NE flags may limit where a product can be obtained; failing to use an approved source can cause claim processing issues.

Background Information

Background: biological products are complex therapies distinct from small-molecule generics; some biologics have biosimilars or interchangeable biosimilars that may be substituted per applicable law. The formulary treats biologic and biosimilar entries individually, and many biologic agents in the extract are listed with PA and specific quantity limits that must be followed for coverage decisions.

Legend and Abbreviations

inv-112: Generic drug — definition

Generic drug — definitionA generic drug is FDA‑approved to have the same active ingredient as the brand‑name drug and may be substituted per state law

Original biological product / biosimilarBiological products have biosimilars; interchangeable biosimilars may be substituted per state law

PA (Prior Authorization)Requires approval from Priority Health Medicare before filling; lack of approval may result in non‑coverage

inv-113: Original biological product / biosimilar — definition

Original biological product / biosimilarBiosimilars are analogous alternatives to original biological products; interchangeable biosimilars may be substituted without a new prescription depending on state law

Biosimilar substitution noteBiological products are more complex and use biosimilars rather than generic equivalents

Reference to Evidence of CoverageSee Evidence of Coverage, Chapter 5, Section 3.1 for Part D coverage details

inv-114: PA — Prior Authorization definition

PA — Prior AuthorizationPriority Health Medicare requires prior authorization for certain drugs; approval must be obtained before dispensing or coverage may be denied

PA documentationPhysician may need to submit information describing drug use and setting (Part B vs Part D determinations) and clinical rationale

Consequence of no PAFailure to obtain PA may result in non‑coverage or denial

inv-114-duplicate: PA / QL / ST — key definitions (supporting citations)

PA — Prior Authorization (definition)Requires approval from the plan before prescription is filled; lack of approval may result in non‑coverage

Quantity Limits (QL) — definitionMaximum quantity allowed per time period (EA, ML, GM) as specified for each product

Step Therapy (ST) — definitionRequirement to try specified drugs first before covering alternatives

inv-116: Tiers — tier definitions

T1 — Preferred genericLowest tier (preferred generic)

T3 — Preferred brandPreferred brand tier

T5 — SpecialtySpecialty tier; Tier 5 drugs are limited to 30‑day supply

T6 — InfertilityInfertility tier

inv-117: HI — Home Infusion definition

HI — Home InfusionIndicates the drug may be administered via home infusion and may be covered under the medical benefit; contact Customer Care for details

B/D — Part B vs Part DFlag indicating drug may be billed under Medicare Part B or Part D depending on setting/use

NE — No Express ScriptsNot available via Express Scripts Home Delivery

inv-118: Abbreviations — legend meanings (T1-T6, PA, QL, ST, NE, B/D)

Formulary abbreviations (key)B/D = Part B vs Part D; EA = Each; ED = Excluded Drug; HI = Home Infusion; LA = Limited Availability; NE = No Express Scripts; PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; ML = Milliliters; GM = Grams

EA — EachUnit used for count‑based QLs (EA)

ML / GM unitsVolume (mL) and weight (g) units used for QLs where applicable

inv-119: PA — Prior Authorization note (definition duplicate/legend)

PA — Prior Authorization (plan action)Plan requires prescriber to get approval before drug is filled; lack of approval may result in noncoverage

ST — Step TherapyMember may be required to try specified preferred drugs before coverage of non‑preferred alternatives

QL — Quantity LimitsMaximum allowed quantity per period must be adhered to when submitting claims and authorizations

inv-120: QL — Quantity Limits definition

QL — Quantity Limits (definition)Maximum quantity allowed per specified time period (examples shown in the formulary: '30 EA per 30 days', '2 ML per 28 days', etc.)

ST — Step Therapy (definition)Requirement to try specified drugs first before coverage of alternatives

ED — Excluded Drug (definition)Drug not normally covered in a Medicare Prescription Drug Plan

inv-121: LA — Limited Availability definition

LA — Limited AvailabilityIndicates product supply or access limitations noted by the plan

NE — No Express ScriptsNot available through Express Scripts home delivery

B/D — Part B vs Part DFlag used when billing may be Part B or Part D depending on setting/use

inv-122: T5 — Specialty tier note (30-day supply rule)

T5 — Specialty tier noteTier 5 drugs are specialty; note indicates Tier 5 drugs are 30‑day supply only

T1–T4 summaryT1 = Preferred generic; T2 = Generic; T3 = Preferred brand; T4 = Non‑preferred drug

T6 — InfertilityT6 reserved for infertility agents

inv-123: Abbreviations (formulary key) — expanded legend

Formulary legend (expanded)Lists T1–T6, B/D, EA, ED, HI, LA, NE, PA, QL, ST, ML, GM — used across the formulary entries

EA — Each (unit)Used for countable dose limits (EA)

ST — Step Therapy (legend)Indicates step therapy requirement may apply where flagged

inv-124: Tier definitions / abbreviations — T1-T6 and others

Tiers (T1–T6)T1 Preferred generic; T2 Generic; T3 Preferred brand; T4 Non‑preferred; T5 Specialty; T6 Infertility

PAPrior Authorization — plan approval required before coverage

QLQuantity Limit — maximum allowed per specified time period

inv-125: Legend abbreviations — formulary legend definitions

PA (Prior Authorization)Requires prescriber to obtain plan approval prior to dispensing; failure to obtain PA may lead to denial

QL (Quantity Limits)Specified maximum quantities (EA/ML/GM) per defined period must be followed

ED (Excluded Drug)Not normally covered under Medicare Part D; payments do not count toward total drug costs

inv-126: QL — Quantity Limits as specified

QL — as specifiedQuantity Limits are expressed per period (e.g., EA per 30 days; ML per 28/30 days)

Examples unitsEA = Each; ML = Milliliters; GM = Grams — used in QL expressions

Apply QL to claims/PAQL values should be used to support authorizations and claims submissions

inv-127: PA — Prior Authorization required before coverage

PA — Prior Authorization requirementPrior Authorization required before coverage for drugs flagged 'PA' in the formulary

PA documentation timeframeExceptions and PA decisions referenced elsewhere indicate standard decision times (see policy) — prescriber support required

Denial riskCoverage may be denied if PA is not obtained

inv-128: T1-T6 — tiers summary

T1–T6 summaryFormulary tiers where T1 = Preferred generic, T5 = Specialty, T6 = Infertility

Tier implicationsTier determines cost‑sharing and supply rules (e.g., Tier 5 = 30‑day supply)

Reference noteSee formulary legend for full abbreviations and rules

inv-129: Tier definitions and abbreviations — repeated legend

Tier definitions (concise)T1 Preferred generic; T2 Generic; T3 Preferred brand; T4 Non‑preferred; T5 Specialty; T6 Infertility

Common abbreviationsPA, QL, ST, ED, HI, LA, B/D — used throughout formulary entries

Tier 5 supply ruleTier 5 items limited to 30‑day supply as noted in legend

Continuation and Transition Protections

Continuation/Transition protections

Protections for members already taking drugs and during care-level changes:

Existing member continuity: If a member was taking a drug covered at the beginning of the coverage year, Priority Health generally will not discontinue or reduce coverage for that drug for the remainder of the coverage year except in specified circumstances (e.g., market withdrawal or substitution with an approved generic/biosimilar).

Stability of coverage during the coverage year for current users.

Transition supply during coverage changes: Members experiencing a level-of-care change will be provided a transition supply of at least 30 days of medication unless the prescription is written for fewer days; long-term care residents may receive a 31-day emergency supply for non-formulary drugs while pursuing an exception.30 days

Applies to transitions and care-level changes.

Step Therapy Rules and Notes

Step therapy summary	Source / notes
Try specified drugs first before covering alternatives (Step Therapy may require trial of preferred agent(s) prior to coverage of non-preferred products).
Formulary describes ST in general terms and explains that members may need to try Drug A before Drug B; see 'Are there any restrictions on my coverage?' and abbreviation definitions for ST.

Therapeutic classes / examples with ST	Source / notes
Some therapeutic classes use Step Therapy; members may be required to try preferred antidepressants (examples: FETZIMA, vilazodone, TRINTELLIX) before coverage of other agents.
Abbreviation key defines ST and class entries (FETZIMA, vilazodone, TRINTELLIX) show Requirements/Limits = ST in the formulary listings.

Product	ST details
DIFICID oral suspension (fidaxomicin)
Requirements/Limits = ST; QL (136 ML per 10 days).

Product / class	ST indication
FETZIMA (antidepressant)
Requirements/Limits = ST; QL (30 EA per 30 days) indicated in formulary excerpt.
TRINTELLIX / vilazodone (antidepressants)
Some entries show Requirements/Limits = ST (step therapy) for selected antidepressant products in the formulary listings.
eletriptan (triptan class) and related agents
Formulary notes include 'ST' for certain triptans/antimigraine agents (ST applies where listed).

Legend / definition	Implication
ST = Step Therapy (formulary abbreviation defined in legend).
Legend indicates ST is a possible utilization control but specific step rules are not listed in the excerpt; follow ST where shown on product rows.

Product / strength	ST note
paliperidone ER 1.5 mg, 3 mg, 9 mg
Requirements/Limits = ST; QL (30 EA per 30 days) — ST required for certain paliperidone ER strengths per formulary listing.
paliperidone ER 6 mg
Requirements/Limits = ST; QL (60 EA per 30 days) — strength-specific ST and QL noted in the entry.

ST in legend	Comment
ST is included in the formulary abbreviation list (ST = Step Therapy).
The legend references ST as a requirement code; specific product-level rules must be read on individual drug rows.

Reference	Detail
Abbreviation key (ST)
ST (Step Therapy) appears in the abbreviation key and may apply to products elsewhere in the full formulary; no full ST protocol is provided in excerpt.

Observation	Source
Step Therapy (ST) may apply to drugs listed in other parts of the formulary not included in this excerpt.
Legend and abbreviation references indicate ST is a recognized requirement code; specific drug rows elsewhere will show ST when applicable.

Product	Requirements/Limits
calci triol external (calcitriol external products)
Requirements/Limits = ST (step therapy) noted in formulary excerpt for calcitriol external product.

Example	ST application
ST. clotrimazole-betamethasone external cream
Formulary header/example shows ST applied where indicated (follow ST requirement on product row); QL also specified for clotrimazole-betamethasone cream (120 GM per 30 days).

Abbreviation key	Note
ST listed in the abbreviation key (Step Therapy).
Formulary notes ST among other requirement codes; specific application depends on product-row flags.

Area	ST usage
Ophthalmic agents and anti-inflammatories
ST is applied to selected ophthalmic agents (e.g., travoprost flagged ST; loteprednol and difluprednate entries show ST); follow product row ST requirements for authorization.

Ophthalmic examples	Details
travoprost (ophthalmic prostaglandin)
Listed with Requirements/Limits = ST in ophthalmic prostaglandin section; formulary indicates ST applies to selected prostaglandin agents.
difluprednate / loteprednol (ophthalmic anti-inflammatories)
Entries for difluprednate and loteprednol show Requirements/Limits = ST for some formulations in the ophthalmic anti-inflammatory listings.

Statement	Formulary context
ST referenced in legend but specific ST protocol not included in excerpt.
Multiple product rows (e.g., paliperidone ER, ZYPREXA RELPREVV) include requirement codes and QLs; ST appears as a possible restriction but full step rules are not provided here.

Quantity Limits by Product (Examples)

inv-153: multiple QL examples from excerpt

Fentanyl transdermal patch (72‑hour) — multiple strengthsQL 10 EA per 30 days

Lidocaine external patch 5% / LIDOCANRequirements: PA; QL 90 EA per 30 days

ARIKAYCE (amikacin liposome inhalation)Requirements: PA; QL 235.2 ML per 28 days

inv-154: XIFAXAN 200 MG — QL examples

XIFAXAN 200 mgQL 9 EA per 30 days; PA required

XIFAXAN 550 mgQL 60 EA per 30 days; PA required

Brivaracetam oral solutionQL 600 ML per 30 days; PA required

inv-160: eslicarbazepine acetate — QL examples

Eslicarbazepine acetate (200/400 mg)QL 30 EA per 30 days

Eslicarbazepine acetate (600/800 mg)QL 60 EA per 30 days

Lacosamide oral solutionQL 1200 ML per 30 days

inv-171: INVEGA HAFYERA and RELPREVV examples

INVEGA HAFYERA 1092 mg/3.5 MLQL 3.5 ML per 180 days

ZYPREXA RELPREVV 210/300/405 mg (IM recon)QL 2 EA (210 mg) / 2 EA (300 mg) / 1 EA (405 mg) per 30 days

VERSACLOZQL 540 ML per 30 days; Requirements: PA

Site-of-Care and Benefit Routing

Note

Policy Summary

Payerpriority health

PolicyPriority Health Medicare Employer Group Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJune 1, 2026

Last ReviewMay 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug entry lists 'PA' before dispensing to avoid claim denial.

SourceLink

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Currentpriority healthPolicy N/A

Priority Health Medicare Employer Group Formulary (Drug List) — Coverage Criteria

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Policy Summary

Payerpriority health

PolicyPriority Health Medicare Employer Group Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJune 1, 2026

Last ReviewMay 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a drug entry lists 'PA' before dispensing to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6/1/26formulary current as of

v15document version

30 daystransition supply

72 hrsstandard exception time

24 hrsexpedited exception

30-dayTier 5 supply limit

Coverage Criteria and Formulary Rules

General formulary coverage

Covered when ALL of the following general conditions are met:

See formulary listings and Requirements/Limits for product-specific controls.

Transition and emergency supply

Temporary coverage provisions:

Standard temporary transition supply; see long-term care exception (31 days).

Coverage ends after temporary supply if exception not approved.

Level-of-care change: Members experiencing a level-of-care change will be provided a transition supply of at least 30 days of medication unless the prescription is written for fewer days.30 days

Applies when site-of-care or care-level changes occur.

General coverage rule for listed formulary products

Covered when product is on formulary subject to noted prior authorization and quantity limits:

B/D indicates Part B vs Part D billing; Tier 5 specialty drugs limited to 30-day supply.

Formulary tier and restriction rules

Coverage is determined by formulary tier with specific quantity limits and prior authorization requirements applied where noted.

Refer to tier legend for definitions.

Providers must submit documentation to support PA and requested QL.

Formulary coverage with tier and requirement flags

Coverage and access are governed by tier assignment plus any listed requirement/limit flags. Examples below reflect how the document structures coverage rules for select product groups.

Providers must follow PA/QL/B-D billing instructions where flagged.

PA must be obtained per formulary before coverage is approved.

Prior authorization required

Specialty and high-cost products:

PA must be obtained per formulary before coverage is approved.

PA and QL enforcement: Failure to obtain required prior authorization or exceeding listed quantity limits may result in claim denial or non-coverage for specialty/high-cost drugs.

Providers should submit required documentation per PA process.

Step therapy requirements

Step therapy and utilization management for ophthalmics:

Follow ST protocol and document prior therapeutic trials when requesting authorization.

Coverage with utilization controls

Formulary coverage and utilization controls — drugs are categorized by tier and may have QL, PA, LA, B/D or other restrictions:

Formulary assignment: Drugs are assigned formulary tiers (T1–T6); tier determines cost-sharing and supply rules (e.g., Tier 5 = 30-day supply).

See tier legend for definitions and supply rules.

Claims must meet listed PA and QL rules to be covered; LA and B/D affect availability and benefit routing.

Abbreviations, Codes and Quantity Examples

Abbreviationsmixed

B/D	Part B vs. Part D - drug may require prior authorization and may be covered differently under Medicare Part B (medical) or Part D (prescription) depending on circumstances.
EA	Each
ED	Excluded Drug - not normally covered in a Medicare Prescription Drug Plan; cost does not count toward total drug costs for catastrophic coverage; extra help not available for this drug.
HI	Home Infusion
LA	Limited Availability
NE	No Express Scripts
PA	Prior Authorization
QL	Quantity Limits
ST	Step Therapy
ML	Milliliters

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Common Abbreviations (continued)mixed

T1	Preferred generic
T2	Generic
T3	Preferred brand
T4	Non-preferred drug
T5	Specialty
T6	Infertility

Selected Formulary Products with Quantity Limits (Examples)NDC

ARIKAYCE	QL example: 235.2 ML per 28 days (illustrative)
LIDOCAINE_PATCHES	QL example: 90 EA per 30 days
FENTANYL_PATCH	QL example: 10 EA per 30 days
XIFAXAN_200MG	PA; QL 9 EA per 30 days
XIFAXAN_550MG	PA; QL 60 EA per 30 days
VANCOMYCIN_ORAL_CAPSULE_125MG	QL 80 EA per 30 days (125 mg)
VANCOMYCIN_ORAL_CAPSULE_250MG	QL 160 EA per 30 days (250 mg)

Formulary Entries with PA/QLNDCCovered

XIFAXAN_200MG	PA; QL (9 EA per 30 days)
XIFAXAN_550MG	PA; QL (60 EA per 30 days)

Vancomycin FormulationsNDCCovered

VANCOMYCIN_IV_RECONSTITUTED_1GM	Home Infusion (HI) for IV reconstituted 1 gm; tier varies
VANCOMYCIN_ORAL_CAPSULE_125MG	Oral capsule 125 mg; QL 80 EA per 30 days
VANCOMYCIN_ORAL_CAPSULE_250MG	Oral capsule 250 mg; QL 160 EA per 30 days

Anticonvulsants / Specialty AgentsNDCCovered

BRIVARACETAM	PA; QL examples (oral solution/tablet)
EPIDIOLEX	PA; QL (500 ML per 30 days)
FINTEPLA	PA; QL (360 ML per 30 days)
XCOPRI	PA; QL (varies by strength)

Placeholder - No CPT/HCPCS/ICD codes in excerptmixed

No codes listed

Drugs with Specified Strengths (examples)NDC

TRULICITY_AUTOINJECTOR	PA; QL (2 ML per 28 days)
XARELTO_10MG	QL (30 EA per 30 days)
XARELTO_15MG	QL (60 EA per 30 days)
ENOXAPARIN_PREFILLED_30MG	QL (18 ML per 30 days)
ENOXAPARIN_PREFILLED_40MG	QL (24 ML per 30 days)
ENOXAPARIN_PREFILLED_60MG	QL (36 ML per 30 days)
INVEGA_SUSTENNA_PREFILLED	QL examples by strength (ml per 30 days)

Formulary drug listings and limits (cardiovascular examples)NDC

CANDESARTAN_4MG	Tier 2; QL 240 EA per 30 days
CANDESARTAN_8MG	Tier 2; QL 120 EA per 30 days
CANDESARTAN_16MG	Tier 2; QL 60 EA per 30 days
CANDESARTAN_32MG	Tier 2; QL 30 EA per 30 days
IRBESARTAN_75MG	Tier 1; QL 120 EA per 30 days
IRBESARTAN_150MG	Tier 1; QL 60 EA per 30 days
IRBESARTAN_300MG	Tier 1; QL 30 EA per 30 days
LOSARTAN_25MG	Tier 1; QL 90 EA per 30 days
LOSARTAN_50MG	Tier 1; QL 60 EA per 30 days
LOSARTAN_100MG	Tier 1; QL 60 EA per 30 days

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Formulary requirement codes and examplesmixed

PA	Prior Authorization required for certain products (see entry)
QL	Quantity limits specified per product and strength (see entry)
HI	Home Infusion requirement noted for some IV products
B/D	Medicare Part B vs Part D note applies for specified items
ST	Step therapy requirement applies to certain ophthalmic and dermatologic agents

Sample formulary drug entries (partial)NDC

LISINOPRIL_2.5MG	Tier 1; example strengths listed
LISINOPRIL_10MG	Tier 1; QL 120 EA per 30 days
LISINOPRIL_20MG	Tier 1; QL 60 EA per 30 days
BENAZEPRIL_5MG	Tier 1; QL 480 EA per 30 days
BENAZEPRIL_10MG	Tier 1; QL 240 EA per 30 days
BENAZEPRIL_20MG	Tier 1; QL 120 EA per 30 days
BENAZEPRIL_40MG	Tier 1; QL 60 EA per 30 days
ENALAPRIL_2.5MG	Tier 1; QL 480 EA per 30 days
ENALAPRIL_5MG	Tier 1; QL 240 EA per 30 days

Biologic / Biosimilar entriesNDC

REPATHA	PA; QL (2 ML per 28 days)
DUPIXENT_300MG_2ML	PA; QL (8 ML per 30 days)

Selected Vaccines and Quantity-Limited ProductsNDCCovered

SHINGRIX	QL (1-2 EA per long interval; see formulary)
AREXVY	QL (1 EA per 720 days)
MRESVIA	QL (0.5 ML per 720 days)
PENBRAYA	QL (2 EA per 720 days)
JYNNEOS	Requirements/Limits = B/D
IMOVAX_RABIES	Requirements/Limits = B/D

Metabolic Bone Disease / Specialty InjectablesNDCCovered

EVENITY	PA; QL (2.34 ML per 30 days)
TERIPARATIDE_PEN	PA; QL (2.48 ML per 30 days)
TYMLOS	PA; QL (1.56 ML per 30 days)
ZOLEDRONIC_ACID_IV	B/D for IV formulations

Ophthalmic agents with PA/QL/STNDCCovered

RESTASIS_MULTIDOSE_0.05%	QL (5.5 ML per 30 days)
CYSTADROPS	PA; QL (20 ML per 30 days)
OXERVATE	PA; QL (28 ML per 30 days)
LUMIGAN_0.01%	tiered
DIFFLUPREDNATE	ST (step therapy) applies

Otic and Respiratory agentsNDCCovered

CIPROFLOXACIN_DEXAMETHASONE_OTIC	QL (7.5 ML per 30 days)
ALBUTEROL_HFA	QL (17-36 GM per 30 days depending on NDC)
INCRUSE_ELLIPTA	QL (30 EA per 30 days)

Placeholder - No billing codes listedmixed

No codes listed

Prior Authorization, Step Therapy, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

PA applies to many specialty, high‑cost, and selected non-specialty products across the formulary (see PA flags in drug listings).
Common PA triggers: specialty tier drugs (T5), selected oncology, immunologic, pulmonary, genetic/enzyme replacement, and other high-cost agents.
Examples of drugs requiring PA include (non‑exhaustive): XIFAXAN (200 mg and 550 mg), selected anticonvulsants (brivaracetam, EPIDIOLEX, rufinamide, etc.), DIFICID formulations, many oncology agents (e.g., VENCLEXTA, TAGRISSO), specialty biologics (e.g., DUPIXENT, REPATHA), pulmonary/cystic fibrosis products (TRIKAFTA, ORKAMBI), and multiple other PA‑flagged items throughout the formulary.

Documentation Required

Part B vs Part D — Documentation May Be Required

Some drugs are subject to a Part B vs. Part D (B/D) determination and may require additional documentation from the prescribing provider to establish the setting of use and benefit routing.

When a B/D flag appears, submit clinical documentation describing the drug’s use and administration setting to support Part B coverage when applicable.
Examples where B/D is indicated: certain infused or injectable agents and some inhalation/medical‑benefit products (see drug line entries).

Documentation Required

Quantity Limits and Documentation

Submit requested quantity and intended days’ supply on PA submissions. QLs shown in each drug row (e.g., XIFAXAN 200 mg QL = 9 EA per 30 days; XIFAXAN 550 mg QL = 60 EA per 30 days).
Tier 5 drugs are limited to 30‑day supply only unless otherwise noted.
LA (Limited Availability) items may be available only at select pharmacies — check Provider/Pharmacy Directory or contact Customer Care.

Step Therapy

Step Therapy (ST) Requirements

Step therapy (ST) requirements are used for select agents: prescribers must document prior trials of required drugs or clinical rationale for bypassing the step protocol when requesting an exception.

DIFICID oral suspension and tablets carry ST plus QL (see entries) — prescribers must document prior use/ failure of preferred therapy where applicable.
ST is referenced across multiple classes (e.g., some antidepressants, ophthalmic agents, paliperidone ER strengths) — follow the ST flag in the formulary and provide prior trial records in PA/exception requests.
If requesting an exception to ST, include the prescriber’s supporting statement explaining why the step requirement is medically inappropriate or harmful; exception decisions are generally rendered within 72 hours (24 hours for expedited requests).

Documentation Required

Prior Authorization Documentation and Timing

Priority Health generally must make a determination within 72 hours of receiving the prescriber’s supporting statement; expedited reviews (24 hours) are available when waiting could seriously harm the member.
Documentation supports PA, QL exceptions, ST exemptions, and B/D determinations — incomplete submissions may delay or trigger denials.

Denial Risk

Denial Risk from Unmet Utilization Controls

ED (Excluded Drug) entries are not covered and will be denied — examples include certain topical/emollient formulations and listed vitamins or pumps marked ED.
Drugs marked PA or with QL exceedances may be denied at claim adjudication without an approved authorization.
LA or NE flags may limit where a product can be obtained; failing to use an approved source can cause claim processing issues.