Priority Health Medicare 2026 Formulary (Drug List) - Coverage Criteria
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This document is the 2026 formulary (drug list) for Priority Health Medicare, describing covered drugs, applicable restrictions (prior authorization, quantity limits, step therapy), member rights to exceptions and transitions, and how to use the formulary. It affects plan members, prescribers, and network pharmacies using Priority Health Medicare benefits.
No material clinical or coverage changes in this revision.
Formulary Coverage & Requirements
General formulary coverage and exception process
Covered when plan rules and any listed requirements/limits are met.
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Formulary coverage with requirements
Coverage depends on tier and any listed requirements/limits; specific drugs require PA, QL, ST, or are HI-designated.
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General coverage approach for listed drugs
Coverage follows formulary tier assignment with utilization controls as listed; drugs with PA/ST/QL have restrictions.
Providers must follow PA/ST/QL listed for each product (see formulary entries).
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Formulary coverage entries (per-drug)
Coverage and utilization management per drug as listed (examples below).
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Formulary listing and administrative controls
Coverage is determined by formulary tier and the listed requirements/limits for each product.
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Coverage controls (PA/QL/HI) and formulary tiering
Coverage and use constraints for listed drugs are indicated by tier assignments and specific controls; coverage is subject to PA, QL, HI, or other plan rules as annotated below.
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General coverage by tier
Coverage is determined by formulary tier and any listed requirements/limits.
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PA / QL constrained coverage
Prior authorization and quantity limits apply to specific agents.
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Formulary tiering and requirement flags
Coverage and requirement indicators shown per drug
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Specialty agent PA/QL/LA conditions
Coverage and utilization management for specialty and high-cost agents:
Examples: CF agents, pulmonary hypertension agents, pulmonary fibrosis agents (chunks 262–265).
Ophthalmic ST/QL
Utilization controls for ophthalmic anti-inflammatories:
Examples: difluprednate and loteprednol are listed with ST; ketorolac 0.5% has QL 20 ML per 30 days (chunks 254–255).
Excluded drugs (abbreviated ED) are not normally covered under a Medicare Prescription Drug Plan. Amounts members pay for an ED do not count toward total drug costs (for example, they do not help a member qualify for catastrophic coverage), and members receiving extra help will generally not receive additional subsidies for these drugs. Coverage for excluded drugs may be available only on specific Priority Medicare offerings (for example, Priority Medicare® Thrive and Priority Medicare® Thrive Plus).
Formulary entries flagged NE (No Express Scripts) or ED (Excluded Drug) indicate restricted dispensing or lack of coverage through Express Scripts home delivery or exclusion from normal Part D coverage; check the line‑item entry for the specific product. Specialty drugs assigned to Tier 5 are managed with utilization controls shown in the Requirements/Limits column — e.g., many Tier 5 agents require PA (prior authorization) and often carry QL (quantity limits). Examples in this formulary include AUVELITY and EXXUA (Tier 5; PA; QL) and DIFICID products which carry ST (step therapy) plus QL entries.
Specialty medications listed as Tier 5 are subject to a supply limitation of a 30‑day supply only. This supply rule is noted in the formulary legend and is applied to Tier 5 entries throughout the drug list; confirm the per‑product QL where a specific quantity limit is provided.
Formulary Listings & Coding / Quantity Examples
| fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr | fentanyl transdermal patch 72 hour — listed with tier and QL |
| lidocaine external patch 5% | lidocaine external patch 5% — PA; QL (90 EA per 30 days) |
| KLOXXADO | Opioid reversal agent — QL (2 EA per 30 days) |
| ARIKAYCE | ARIKAYCE — Tier 5; PA; QL (235.2 ML per 28 days) |
| XIFAXAN ORAL TABLET 200 MG | PA; QL (9 EA per 30 days) |
| XIFAXAN ORAL TABLET 550 MG | PA; QL (60 EA per 30 days) |
| No codes listed |
| AUVELITY | AUVELITY — Tier 5; Requirements/Limits = PA; QL (60 EA per 30 days); NE |
| EXXUA | EXXUA — Tier 5; Requirements/Limits = PA; QL (30 EA per 30 days) |
| ZURZUVAE ORAL CAPSULE 20 MG/25 MG/30 MG | ZURZUVAE ORAL CAPSULE 20 MG/25 MG/30 MG — Tier 5; Requirements/Limits = PA; QL (28 EA per 365 days for 20/25 mg; 14 EA per 365 days for 30 mg) |
| EMSAM | EMSAM — Tier 5; Requirements/Limits = PA |
| MARPLAN | MARPLAN — Tier 4; Requirements/Limits = PA; QL (180 EA per 30 days) |
| DRIZALMA | DRIZALMA SPRINKLE ORAL CAPSULE DR 20/30 MG — Tier 4; Requirements/Limits = PA; QL (60 EA per 30 days) |
| FETZIMA | FETZIMA — Tier 4; Requirements/Limits = ST; QL (30 EA per 30 days); NE |
| TRINTELLIX | TRINTELLIX — Tier 4; Requirements/Limits = ST; QL (30 EA per 30 days); NE |
| QL (49 EA per 28 days) | Quantity limit for KISQALI FEMARA (200 MG DOSE) |
| QL (70 EA per 28 days) | Quantity limit for KISQALI FEMARA (400 MG DOSE) |
| QL (91 EA per 28 days) | Quantity limit for KISQALI FEMARA (600 MG DOSE) |
| QL (8 EA per 28 days) | Quantity limit example for XPOVIO (100 mg once weekly) pack |
| QL (16 EA per 28 days) | Quantity limit example for XPOVIO (40 mg once weekly) pack |
| QL (60 EA per 30 days) | Quantity limit example for VITRAKVI 100 mg |
| QL (90 EA per 30 days) | Quantity limit example for VITRAKVI 25 mg |
| ZYKADIA | ZYKADIA ORAL TABLET (Tier 5) - PA |
| bexarotene external | bexarotene external (Tier 5) - PA; QL (60 GM per 30 days) |
| bexarotene oral | bexarotene oral (Tier 5) - PA |
| tretinoin oral | tretinoin oral (Tier 5) - PA |
| leucovorin calcium oral | leucovorin calcium oral (Tier 2) |
| mesna oral | mesna oral (Tier 4) |
| albendazole oral | albendazole oral (Tier 4) |
| ivermectin oral tablet 3 mg | ivermectin oral tablet 3 mg (Tier 3) |
| COARTEM | COARTEM (Tier 4) - QL (24 EA per 30 days) |
| IMPAVIDO | IMPAVIDO (Tier 5) - PA; QL (84 EA per 28 days) |
| EA | Each (unit used in quantity limits) |
| ML | Milliliters (unit used in quantity limits) |
| QL (15 ML per 25 days) | SOLIQUA quantity limit |
| QL (60 EA per 30 days) | dabigatran etexilate mesylate quantity limit example |
| QL (74 EA per 30 days) | ELIQUIS DVT/PE starter pack quantity limit |
| QL (620 ML per 30 days) | XARELTO oral suspension recon. quantity limit |
| PA | Prior Authorization flag (applies to multiple items e.g., novofine pen needle, NIVESTYM) |
| B/D | Part B vs Part D billing designation (applies to products like PROCRIT certain strengths) |
| N/A | No explicit CPT/HCPCS/ICD-10/NDC codes provided in this segment; only medication names, strengths, tiers, and requirements are listed. |
| methylphenidate hcl er (osm) oral tablet extended release 18 mg | Drug Tier = 4; QL (30 EA per 30 days) |
| methylphenidate hcl er (osm) oral tablet extended release 54 mg | Drug Tier = 4; QL (30 EA per 30 days) |
| methylphenidate hcl er oral tablet extended release 27 mg | Drug Tier = 4; QL (60 EA per 30 days) |
| methylphenidate hcl oral solution 10 mg/5ml | Drug Tier = 4; QL (1500 ML per 30 days) |
| AUSTEDO ORAL TABLET 12 MG, 9 MG | Drug Tier = 4; Requirements/Limits = PA; QL (120 EA per 30 days) |
| AUSTEDO ORAL TABLET 6 MG | Drug Tier = 4; Requirements/Limits = PA; QL (60 EA per 30 days) |
| AUSTEDO XR | Drug Tier = 4; Requirements/Limits = PA; QL (30 EA per 30 days) |
| EVRYSDI ORAL TABLET | Drug Tier = 5; Requirements/Limits = PA; QL (30 EA per 30 days) |
| tetrabenazine oral tablet 12.5 mg | Drug Tier = 4; Requirements/Limits = PA; QL (90 EA per 30 days) |
| tetrabenazine oral tablet 25 mg | Drug Tier = 5; Requirements/Limits = PA; QL (120 EA per 30 days) |
| No codes listed |
| QL (8 ML per 28 days) | Quantity limit example for COSENTYX, ENBREL and others as listed |
| QL (3.42 ML per 30 days) | Quantity limit for certain DUPIXENT presentations |
| QL (1.34 ML per 30 days) | Quantity limit for DUPIXENT 100 mg prefilled syringe |
| QL (0.5 ML per 28 days) | Quantity limit for SELARSDI / YESINTEK 45 mg |
| QL (1 ML per 28 days) | Quantity limit for SELARSDI 90 mg |
| PA | Prior authorization required (multiple listed agents) |
| B/D | Part B vs. Part D designation (used for some agents) |
| No codes listed |
| AZASITE | AZASITE (ophthalmic) |
| NATACYN | NATACYN (ophthalmic) |
| ZIRGAN | ZIRGAN (ophthalmic) |
| ALPHAGAN P | ALPHAGAN P OPHTHALMIC SOLUTION 0.1% |
| COMBIGAN | COMBIGAN |
| SIMBRINZA | SIMBRINZA |
| CAYSTON | CAYSTON (CF agent) |
| KALYDECO | KALYDECO (CF agent) |
| ORKAMBI | ORKAMBI |
| PULMOZYME | PULMOZYME INHALATION SOLUTION 2.5 MG/2.5ML |
| QL (example) | Quantity limit examples such as 'QL (30 ML per 30 days)', 'QL (21 GM per 30 days)', 'QL (60 EA per 30 days)' |
Prescriber Requirements, Prior Authorization & Step Therapy
Obtain PA and document B/D setting
Certain drugs require prior authorization and some may have Part B vs Part D (B/D) billing considerations; prescribers must submit documentation of the drug's use and setting to determine benefit routing and obtain PA before the prescription is filled to ensure coverage. Failure to obtain PA may result in noncoverage.
- Prescriber must submit information describing drug use/setting for B/D determination (chunk 18).
- Obtain prior authorization before filling; lack of PA may result in noncoverage (chunk 12, 21).
Prior authorization required before dispensing
Priority Health Medicare requires prior authorization for many listed drugs — prescribers must obtain PA approval before the prescription is filled to avoid denial or noncoverage.
- PA flag appears next to numerous specialty and Tier 4–5 agents; submit PA per plan procedures (chunks 21, 90).
- If PA is not obtained, the drug may not be covered (chunk 12).
Get PA for specialty/injectable and HI drugs
Select specialty/injectable agents and some home-infusion products are subject to prior authorization and/or home infusion channel requirements; obtain PA and route claims per the HI designation when applicable.
- Examples include ARIKAYCE and other IV/infusion antibiotics that have PA and HI flags (chunks 50, 52).
- Home infusion designation (HI) may require billing under medical benefit and appropriate authorization (chunk 50).
PA + QL for lidocaine 5% patch (90 EA/30 days)
Lidocaine external patch 5% requires prior authorization and is limited to 90 each per 30 days; do not exceed the listed quantity without prior approval.
- Lidocaine external patch 5% — Requirements/Limits = PA; QL (90 EA per 30 days) (chunk 45).
Submit PA for listed specialty/high‑tier agents
Certain specialty or high-tier drugs are marked 'PA' and require prior authorization; prescribers must submit PA documentation for those agents (examples include brivaracetam, EPIDIOLEX, FINTEPLA, and selected XCOPRI presentations).
- Brivaracetam oral solution/tablet — PA; QL (600 mL / 60 EA per 30 days) (chunk 63).
- EPIDIOLEX and FINTEPLA are listed with PA and QL requirements (chunk 63).
PA required for many Tier‑4/5 drugs
Multiple Tier‑4 and Tier‑5 drugs are annotated with 'PA' in the Requirements/Limits column; obtain prior authorization for listed agents such as AUVELITY, EXXUA, ZURZUVAE, EMSAM, MARPLAN, DRIZALMA, CRESEMBA and numerous antineoplastics before coverage is approved.
- AUVELITY, EXXUA, ZURZUVAE — Requirements/Limits = PA (chunk 72).
- Many antineoplastics (e.g., STIVARGA, VITRAKVI, KISQALI FEMARA) are marked PA; submit PA as required (chunks 105, 90).
Obtain PA for specialty formulary entries
PA appears next to most specialty drug entries; providers must obtain prior authorization for those drugs to secure coverage.
- Claims for listed specialty drugs may be denied or require review if PA is not obtained (chunk 90).
- Many oncology and specialty oral agents list PA and QL (chunk 105).
PA required for listed PA drugs (brands/specialty)
Many specialty and brand drugs in the formulary list 'PA' — providers must obtain prior authorization before coverage will be approved for these line‑items (examples include ZYKADIA, CAPLYTA, VERSACLOZ, NUPLAZID).
- ZYKADIA and multiple retinoids/oncology agents are PA‑designated (chunk 108).
- Aripiprazole oral solution and other psychiatric specialty products show PA and QL expectations (chunk 114).
PA applies to GLP‑1 and insulin supplies
Certain products (including some GLP‑1 agents and insulin supplies) require prior authorization; follow PA procedures for products such as MOUNJARO, OZEMPIC, RYBELSUS and listed insulin supplies.
- MOUNJARO — Requirements = PA; QL (2 mL per 28 days) (chunk 137).
- OZEMPIC — Requirements = PA; QL (3 mL per 28 days) for certain formulations (chunk 138).
- Insulin supplies/pen needles are marked PA per entries (chunk 141).
PA required for selected specialty/brand drugs
Some listed specialty/brand agents (e.g., REPATHA, REPATHA PUSHTRONEX, ENTRESTO formulations, NEXLETOL/NEXLIZET) require prior authorization; submit PA per plan instructions to avoid denial.
- REPATHA products have QL and are PA‑designated depending on formulation (chunk 175).
- Multiple cardiovascular and neuromuscular specialty agents list PA (chunk 181).
Submit PA for numerous specialty agents
Numerous drugs — including AUSTEDO, AVONEX formulations, fingolimod, glatiramer products, EBGLYSS, OTEZLA and tolvaptan — are marked 'PA' and require prior authorization; providers must submit PA to obtain coverage.
- AUSTEDO entries show Requirements/Limits = PA and QL (chunk 181).
- Tolvaptan is marked PA with QL (120 EA per 30 days) in oncology/pulmonary listings (chunks 182, 199).
PA required for many specialty injectables
Multiple specialty and high‑cost injectables are designated 'PA' — obtain prior authorization for products such as COSENTYX, DUPIXENT, SKYRIZI, TAVNEOS, XOLAIR, ENBREL and related biologics before dispensing.
- COSENTYX, DUPIXENT, SKYRIZI show PA and specified QLs (chunk 228‑230).
- ENBREL and adalimumab presentations are PA‑designated with QL examples provided (chunk 235).
Obtain PA for listed specialty/brand products
Many specialty and select brand products list 'PA' in the formulary; providers must request and receive prior authorization for those agents (see line‑item entries listing 'PA').
- Adalimumab‑adaz and HUMIRA/HADLIMA formulations list PA and QL per presentation (chunks 234‑236).
- Follow the PA submission process for these products to secure coverage (chunk 235).
PA (± QL/LA) for selected specialty agents
Certain cystic fibrosis, pulmonary hypertension, and pulmonary fibrosis agents are subject to prior authorization and may also have quantity limits or limited availability; submit PA and any required QL documentation for coverage.
- CF agents (e.g., TRIKAFTA) and ORKAMBI show PA/QL designations (chunk 263).
- Pulmonary fibrosis agents like pirfenidone are PA‑designated with QLs (chunk 266 referenced in inventory).
Follow Step Therapy and document prior trials
Step therapy may require trying specified alternative drugs first before covering another drug for the same condition; providers must document trial and failure or intolerance when requesting coverage for the next‑line therapy.
- Step therapy requires trial of first‑line agent(s) before covering alternatives; documentation of failure/intolerance is expected (chunks 12, 21).
- DIFICID and select antidepressants/antineoplastics list ST as a requirement where indicated (formulary entries).
Document required step therapy completion
Step therapy is referenced across the formulary legend and specific entries; when a drug lists 'ST' the provider must ensure documented completion or failure of required steps before coverage will be approved.
- Selected drugs (e.g., DIFICID) require ST prior to coverage (chunk 59).
- FETZIMA, TRINTELLIX and other agents are listed with 'ST' indicating step therapy must be satisfied (chunk 72, 74).
Per-Drug Quantity Limits (Selected Examples)
Home Infusion, Infusion Center & Billing (Part B vs D)
Abbreviations, Tier Definitions & Terms
Transition and Continuation Rules
Transition supply
Transition and temporary supply rules
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Step Therapy Rules & Examples
| Step | Requirement | Notes |
|---|---|---|
| 1 | ||
| Must try specified first-line drugs before escalation to alternative therapies. | ||
| If initial required drug does not work or is not tolerated, documentation may be required to allow coverage of the next-line agent. |
| Agent / Class | Requirement | Quantity Limit (as listed) |
|---|---|---|
| DIFICID oral suspension | ||
| ST (Step Therapy) required prior to coverage | ||
| QL (136 mL per 10 days) | ||
| DIFICID oral tablet | ||
| ST (Step Therapy) required prior to coverage | ||
| QL (20 EA per 10 days) |
| Agent | Requirement | Quantity Limit / Notes |
|---|---|---|
| FETZIMA | ||
| ST (Step Therapy) | ||
| QL (30 EA per 30 days); NE flag noted | ||
| TRINTELLIX | ||
| ST (Step Therapy) | ||
| QL (30 EA per 30 days) | ||
| vilazodone | ||
| ST (Step Therapy) | ||
| (listed with ST in formulary entries) | ||
| eletriptan | ||
| ST (Step Therapy) | ||
| (antimigraine agents include ST flags where indicated) |
| Agent | Requirement | Notes |
|---|---|---|
| travoprost (bak-free) | ||
| ST (Step Therapy) applies | ||
| Listed in ophthalmic agents with ST flag (Tier 3) |
| Agent / Formulation | Requirement | Quantity Limit / Notes |
|---|---|---|
| difluprednate (ophthalmic) | ||
| ST (Step Therapy) required | ||
| Listed under Ophthalmic Anti-Inflammatories with ST; QLs vary by formulation where shown | ||
| loteprednol etabonate ophthalmic gel / suspension | ||
| ST (Step Therapy) required | ||
| Listed with ST; specific QL not shown in this excerpt |
Background & Policy Scope
Biological products are complex medicines distinct from typical small‑molecule drugs; they may have biosimilar alternatives rather than conventional generics. Some biosimilars are designated as interchangeable under state law and may be substituted without a new prescription where allowed. The formulary groups biologic and other agents by therapeutic class and provides abbreviation definitions (for example PA, QL, ED, HI) to guide coverage and dispensing rules.
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