Prior Authorization Required

Certain drugs on the formulary require Prior Authorization (PA) and some carry a B/D designation indicating Part B vs. Part D coverage differences. Providers must obtain prior authorization from Priority Health Medicare before dispensing drugs with PA; failure to obtain PA may result in claim denials or non-coverage. For B/D-designated products, clinicians may need to submit documentation describing the drug’s use and setting so the plan can determine whether Medicare Part B (medical benefit) or Part D (prescription drug benefit) applies.

• PA = Prior Authorization (approval required before filling)
• B/D = Part B vs. Part D (may affect coverage pathway and documentation)

Prior Authorization Requirements

Providers must obtain prior authorization for many specialty, non-preferred, infusion, home-infusion (HI) and certain high-cost agents listed in the formulary. When a Requirements/Limits field shows PA (and/or QL, ST, HI, LA), prescribers must submit supporting clinical documentation that justifies medical necessity and demonstrates that any specified criteria (including step therapy or prior trials of alternatives) have been met.

• Prescriber statement should describe the medical indication, prior therapies tried (if applicable), and the care setting for B/D determinations
• Expedited (72-hour to 24-hour) exception/appeal timelines apply when clinically necessary

Prior Authorization for Listed Drugs

Prior authorization is required for many listed drugs and devices across therapeutic classes — examples from the formulary include: AUVELITY, EXXUA, ZURZUVAE, multiple anticonvulsants (brivaracetam, EPIDIOLEX), select oncology and molecular targeted agents (KISQALI, LUMAKRAS, LYNParZA), biologics and immunomodulators (DUPIXENT, COSENTYX, REPATHA), and numerous specialty injectables and infusion agents. Requirements/Limits entries in the formulary indicate PA, QL, ST, HI or LA as applicable.

• Many specialty biologics and injectables show PA plus a quantity limit (QL)
• Home infusion (HI) and Limited Availability (LA) items may have separate routing or site-of-care requirements

Prior Authorization Required for Drugs & Devices

The formulary lists numerous drugs and devices that require prior authorization and/or have quantity limits or other limits. Examples include select diabetes pens/insulin supplies (pen needles, BD items), oncology agents, blood products and modifiers, cystic fibrosis agents, and many specialty self-injectable biologics. Consult the Requirements/Limits column for each product to determine whether PA (and associated QL, HI, LA, or B/D) applies.

• Examples: pen needles and insulin supplies marked PA (see insulin supplies section)
• Blood products (e.g., PROCRIT) marked B/D — coverage may differ by Part B vs Part D

Prior Authorization for Specialty/Biologic Drugs

Many specialty, biologic and selected non-preferred agents require prior authorization; common examples include adalimumab products, ustekinumab, dupixent, cosentyx, humira, enbrel, and other monoclonal antibody and targeted therapies. For these agents, PA and QL values are commonly listed together; prescribers should confirm required dosing frequency and maximum covered amounts.

• Biologics frequently show PA + QL (e.g., COSENTYX, DUPIXENT, SKYRIZI, REPATHA)
• Many immunosuppressants/immunomodulators include B/D or PA annotations

Prior Authorization for Many Specialty/Biologic Agents

Specialty and biologic agents across the formulary often require prior authorization and quantity limits. Providers must supply clinical rationale and prior-treatment history when requesting PA for these products. Anticipate additional documentation for home infusion (HI) or limited-availability (LA) items, and for B/D-designated drugs where site-of-care/use affects coverage determination.

• Examples: XOLAIR, TRIKAFTA, KALYDECO, and many anti‑TNF/IL agents show PA (and some show B/D or LA)
• Requests for HI-covered agents should note infusion setting and responsible clinician

Authorization Triggers & Denials

Prior authorization triggers include PA entries in the Requirements/Limits column, Step Therapy (ST) requirements, and Quantity Limits (QL). Claims may be edited or denied if the PA was not obtained, if QLs are exceeded, or if ST requirements were not met. Providers should verify formulary notes and the abbreviations legend before submitting prescriptions or claims.

• Common triggers: PA, QL, ST, HI, LA, NE
• Tier 5 (specialty) drugs are generally limited to 30-day supplies — see formulary note

Authorization Denial Risk & Exception Process

Failure to obtain required PA or to adhere to specified QLs or ST rules may result in claim denial or non‑coverage. Providers should document and submit the required supporting clinical information with PA requests. If an exception is needed, prescribers must explain why the formulary alternative is not appropriate; determinations are generally made within 72 hours (24 hours for expedited requests).

• Exceptions allow waiver of PA, ST or QL when medical necessity is demonstrated
• Expedited exception decisions available when delay could seriously harm the patient

Prescriber Documentation Expectations

Providers must include supporting clinical documentation for PA and exception requests: diagnosis, prior therapies/trials, rationale for use of the requested drug, dosing, and the site of administration (especially for B/D or HI items). The formulary’s Requirements/Limits column indicates what documentation is expected; adhere to quantity limits to avoid denials.

• Include prescriber statement describing medical necessity when submitting exceptions or PA requests
• Reference the formulary abbreviations (PA, QL, ST, HI, LA, B/D) on submissions

Formulary Reference & Administrative Notes

Formulary administrative notes and abbreviation keys appear in the formulary (see abbreviation legend and page references). Tier definitions (T1–T5), Tier 5 supply rules (30-day specialty supply only), and a legend for PA/QL/ST/B/D/HI/LA/NE are provided; providers should consult these references when preparing PA requests and when counseling patients about coverage and supply limits.

• Abbreviation legend and tier definitions begin on page 9 of the formulary
• Formulary updated 5/21/2026; effective policy date: 2026-06-01

Quantity Limit Adherence

Quantity limits (QL) are enforced for many products. Providers should follow the QL values shown in the Requirements/Limits column to avoid claim denials or edits. When higher quantities are clinically necessary, submit a PA with supporting rationale or request a formulary exception.

• Examples: XARELTO 10 mg = QL 30 tablets per 30 days; many specialty injectables have ML or mL QLs
• Tier 5 drugs are typically limited to 30-day supplies

Required Documentation for PA and QL Items

When the formulary entry specifies PA or QL, providers must supply the required documentation as noted in the Requirements/Limits field. This includes dosing schedule, prior treatment failures (for ST items), and site-of-care details for B/D or HI-designated drugs. Use the formulary product entry as the authoritative reference for what is required with each PA request.

• Requirements/Limits fields are the operational source for PA, QL, ST, HI, LA and B/D requirements
• Documentation submitted should directly address the criteria listed in the formulary entry

Formulary Abbreviations & Submission Reference

The formulary includes an abbreviation key (PA, QL, ST, B/D, HI, LA, NE, etc.) and tier definitions; prescribers should reference these abbreviations when submitting PA/exception requests. Abbreviation meanings and administrative instructions are found at the beginning of the formulary (see page references in the formulary).

• PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; B/D = Part B vs Part D
• NE = No Express Scripts; HI = Home Infusion; LA = Limited Availability

Step Therapy Requirements & Examples

Step therapy (ST) is applied to certain agents and requires trial of specified formulary alternatives before coverage of the requested drug. Examples include DIFICID, FETZIMA, TRINTELLIX, vilazodone, and selected ophthalmic agents (travoprost bak‑free, difluprednate, loteprednol) which list ST in Requirements/Limits. The formulary legend and individual product entries indicate where ST applies.

• ST examples: DIFICID oral forms (ST + QL), FETZIMA (ST + QL), TRINTELLIX (ST + QL)
• Ophthalmic ST examples: travoprost (bak-free) and certain topical ophthalmic anti‑inflammatories

PA and site‑of‑care/B/D billing considerations for injectables

Prescriptions for specialty injectables and certain biologics may require PA and the plan may determine Part B vs Part D (B/D); providers should contact Customer Care for site‑of‑care or billing pathway questions.

• PROCRIT/RETACRIT entries show B/D — benefit/payment channel may vary.
• Contact Customer Care for home infusion or B/D billing determinations.

Contact Customer Care for HI (home infusion) authorization and coverage

Some products designated 'HI' (Home Infusion) may be covered under the medical benefit rather than the pharmacy benefit; providers should contact Customer Care for authorization and site‑of‑care guidance.

• HI designation appears on IV/infusion products (e.g., ceftazidime, ceftriaxone, vancomycin IV).
• Customer Care contact provided for home infusion coverage details.

Include required documentation for biologic PA submissions

When submitting prior authorization requests for PA‑coded biologics, include the specific documentation referenced by the formulary entry (clinical rationale, prior treatments, and any required site‑of‑care details) to support approval.

• Biologic entries (adalimumab‑adaz, ENBREL, DUPIXENT, COSENTYX) require PA and list QL; include dosing/presentation and clinical history in the PA request.