Prior Authorization Requirement

Prior Authorization Required — Prescribers must obtain prior authorization (PA) from Priority Health Medicare when PA is indicated for a drug. If PA is not obtained before dispensing, the plan may deny coverage for the claim. PA requirements are shown next to individual drugs in the formulary ("PA").

• PA shown next to drugs in formulary entries (see specialty and high-cost listings).
• Failure to obtain PA may result in non-coverage or claim denial.

Prior Authorization — select specialty/high‑cost drugs

Prior authorization is required for select specialty and high-cost drugs. Many Tier 5 (specialty) products, oral oncology agents, biologics, and other high-cost therapies are designated PA and often have an accompanying quantity limit (QL) or other flag (HI, LA, B/D). Examples include ARIKAYCE, colistimethate sodium, XIFAXAN, and numerous oral oncology agents.

• Examples: colistimethate sodium (PA; HI), XIFAXAN 200 mg & 550 mg (PA; QL), many oral oncology agents listed with PA and QL.
• Tier 5 (specialty) drugs are typically 30-day supply only and frequently require PA.

Prior Authorization required for select specialty agents

Prior authorization is required for many specialty agents (Tier 5) and select high‑cost non‑specialty products. These PA requirements are enforced at the point of fill and are often paired with quantity limits (QL) and other routing flags (HI = Home Infusion, B/D = Part B vs Part D, LA = Limited Availability).

• Tier 5 examples with PA: BRIVIACT, EPIDIOLEX, XCOPRI, AUVELITY, EXXUA, ZURZUVAE.
• Home infusion and Part B vs D flags may change documentation or approval routing.

Prior authorization required for listed specialty and named agents

Prior authorization is required for listed specialty and named agents throughout the formulary. Many biologics, immunomodulators, and specialty injectable or infused products show PA with specific QL values.

• Examples: DUPIXENT, SKYRIZI, ustekinumab, adalimumab biosimilars — all flagged PA; QL varies by product.
• Some specialty products also carry LA (limited availability) or require home infusion (HI).

Prior authorization for specialty drugs

Prior authorization applies broadly to specialty drugs; many oral oncology agents, advanced therapies, and specialty oral/IV products require prior approval before coverage will be granted.

• Oral oncology examples with PA and QL: VITRAKVI, VERZENIO, VENCLEXTA, etc.
• Check formulary entries for PA and QL indications before prescribing/dispensing.

Prior Authorization Required — check formulary entries

Prior authorization is indicated next to individual drug entries where required. Review the formulary entry for the PA designation and any associated quantity limits (QL), step therapy (ST), home infusion (HI), Part B vs D (B/D) notes, or limited availability (LA) flags.

• PA notation appears in the Requirements/Limits column for each drug that requires it.
• Other flags (QL, ST, HI, B/D, LA, NE) modify how the drug is routed or documented.

Prior authorization required for specific specialty drugs

Prior authorization is required for specific specialty drugs across therapeutic areas; several high‑cost ophthalmic, pulmonary, and biologic agents are listed with PA and QL.

• Ophthalmic examples: OXERVATE, CYSTADROPS, CYSTARAN, XDEMVY — PA; QL specified per product.
• Pulmonary specialty examples: ADEMPAS, OPSUMIT, OFEV, pirfenidone — PA; QL and sometimes LA flags.

Prior authorization denial risk

Prior authorization denial risk — prescriptions submitted without required PA, exceeding quantity limits, or not meeting step therapy/staging requirements may be denied. Prescribers and providers should confirm PA and QL before dispensing to avoid denials.

• Denials can be triggered by missing PA, exceeding QL, or failure to complete ST requirements.
• Tier 5 specialty drugs commonly trigger PA/QL denials if documentation is incomplete.

Market withdrawal / removed drug

Market withdrawal / removed drug — Priority Health Medicare may immediately remove a drug from the formulary if the manufacturer withdraws it from sale or the FDA withdraws approval for safety or effectiveness reasons. Members will be notified, and a transitional supply or exception process may be available.

• If a drug is removed, affected members will be notified and may receive a temporary supply or instructions to request an exception.
• Other formulary changes (generic entry, biosimilar placement, new restrictions) may be implemented with advance notice.

PA / QL for topical lidocaine

Prior authorization and quantity limits for topical lidocaine — certain topical lidocaine products (patches and kits) require PA and have QL restrictions. Observe the PA/QL flags when prescribing or dispensing.

• Lidocaine external patch 5% and LIDOCAN products: Requirements/Limits = PA; QL (90 EA per 30 days).
• Similar topical lidocaine formulations may have PA and QL—check formulary.

PA / HI requirements for select specialty or IV agents

PA and Home Infusion (HI) requirements — select IV and infused antibiotics and specialty agents require PA and may be routed through home infusion or specialty pharmacy programs. These flags affect coverage determination and documentation routing.

• Examples: colistimethate sodium (PA; HI), daptomycin (Tier 5; HI), cefazolin and cefepime IV forms flagged HI.
• Home infusion designation typically requires additional documentation and may affect benefit administration.

Step therapy / quantity limit denials

Step therapy and quantity limit denials — Failure to satisfy step therapy (ST) requirements or dispensing quantities beyond specified quantity limits (QL) can lead to claim denials. Step therapy may require trying and failing a preferred agent before coverage for an alternative.

• DIFICID entries show ST; QL violations may result in denials.
• Paliperidone ER and selected ophthalmic anti-inflammatories (difluprednate, loteprednol) are examples where ST may apply.

Prior authorization denials for specialty drugs

Prior authorization denials for specialty drugs — Many Tier 5 specialty drugs carry PA and QL requirements; incomplete or missing documentation for these products commonly results in denial of coverage.

• Examples: BRIVIACT, EPIDIOLEX, XCOPRI, AUVELITY — all Tier 5 with PA; ensure documentation supports medical necessity.
• Specialty denials often require prescriber appeal or submission of supporting clinical records.

PA and QL required for many Tier 5 drugs

PA and QL are required for many Tier 5 drugs — Tier 5 (specialty) items are frequently subject to prior authorization, quantity limits, and 30‑day supply restrictions. Check each Tier 5 entry before prescribing.

• Tier 5 drugs are noted as 30-day supply only; PA and QL values are provided per product.
• Examples include many oncology, neurologic, and biologic specialty therapies.

PA required for many specialty drugs

PA required for many specialty drugs across therapeutic classes — review formulary entries for PA, QL, ST, HI, and other flags prior to prescribing or dispensing; these indicators determine coverage and necessary documentation.

• Cardiology, metabolic, and specialty endocrine agents (REPATHA, REDEMPLO, TRYNGOLZA) show PA; QL specified where applicable.
• Oncology and rare disease therapies commonly require PA and have strict QL enforcement.

Quantity limit exceedance

Quantity limit exceedance — Prescriptions exceeding the formulary QL will likely be denied or require prior authorization/exception. Pharmacies and prescribers must observe QL limits at dispensing and claims submission.

• QL examples: XARELTO 10 mg (30 tablets per 30 days), many product-specific QLs listed in formulary entries.
• Exceeding QL may trigger a PA requirement or denial.

Denial triggers from formulary flags

Denial triggers from formulary flags — Coverage denials can be triggered by PA, ED (excluded drugs), QL, ST, B/D routing differences, HI, and LA flags. Confirm the applicable flags and required documentation before filling.

• Common flags: PA (Prior Authorization), QL (Quantity Limits), ST (Step Therapy), HI (Home Infusion), B/D (Part B vs Part D), LA (Limited Availability), ED (Excluded Drug).
• Each flag carries operational implications for coverage and documentation.

PA / QL triggers for specialty drugs

PA/QL triggers for specialty drugs — Many specialty biologics, injectables, and oral specialty agents list both PA and QL; these triggers require prescriber-submitted documentation at the time of prior authorization request and may require ongoing authorization for refills.

• REPATHA, REPATHA Pushtronex, and similar products: PA with specific ML QLs per 28–30 days.
• Specialty injectables frequently require both initial PA and periodic reassessment for continuation.

Prior authorization required for specified products

Prior authorization required for specified products — Many individual products across classes are explicitly listed with PA in the formulary. Prescribers should verify the PA requirement and any associated QL before prescribing.

• Examples: AUSTEDO, EVRYSDI, NUEDEXTA, RADICAVA, tetrabenazine forms — PA and often QL.
• Check therapeutic class sections for product-level PA entries.

FASENRA PA / QL

FASENRA PA/QL — FASENRA prefilled syringe is subject to prior authorization and has a quantity limit noted in the formulary.

• FASENRA prefilled syringe 10 mg/0.5 mL: Requirements/Limits = PA; QL (0.5 ML per 30 days).

PA and QL on testosterone topicals and insulin supplies

PA and QL on testosterone topicals — Transdermal testosterone gels, solutions, and related supplies are subject to prior authorization and quantity limits. Insulin supplies and pen needles also require PA.

• Testosterone transdermal gel products: Requirements/Limits = PA; QL values vary (examples: 150 GM/30 days, 300 GM/30 days, 37.5 GM/30 days).
• Insulin supplies and pen needles listed with PA (assure id insulin safety syringes, BD pen needles, etc.).

PA / QL required for listed specialty ophthalmic agents

PA/QL required for listed specialty ophthalmic agents — Several specialty ophthalmic products require prior authorization and have specific quantity limits; observe these flags when prescribing or dispensing ophthalmic specialty drugs.

• Examples: OXERVATE (PA; QL 28 mL/30 days), CYSTADROPS (PA; QL 20 mL/30 days), XDEMVY (PA; QL 10 mL/180 days).
• Some ophthalmic anti-inflammatories and steroid agents may also be ST-flagged (difluprednate, loteprednol).

PA / QL for pulmonary specialty agents

PA/QL for pulmonary specialty agents — Pulmonary hypertension and interstitial lung disease therapies are commonly PA‑restricted with QLs and sometimes limited availability. Confirm PA before initiating therapy.

• Examples: ADEMPAS, OPSUMIT, ambrisentan, bosentan — Requirements/Limits = PA; QL and LA flags present for some products.
• Prescribers should document diagnosis and prior therapies when requesting PA for pulmonary agents.

Prescriber supporting statement

Prescriber supporting statement — When requesting an exception or prior authorization, the prescriber must provide a supporting statement explaining the medical rationale for the request. For tiering or formulary exceptions, Priority Health Medicare generally decides within 72 hours of receiving the prescriber's supporting statement (24 hours for expedited requests when clinically warranted).

• Prescriber's explanation should describe why alternative formulary drugs are not effective or would cause adverse effects.
• Expedited (fast) decisions are available when waiting could seriously harm the member; decision timeline 24 hours after receiving supporting statement if expedited.

Supporting documentation for requirement codes

Supporting documentation for requirement codes — Providers must supply documentation when submitting PA, QL, ST, HI, LA, B/D, or other flagged requests. Documentation should include clinical indication, prior therapies tried (for ST), dosing, and rationale for exceeding QL if applicable.

• ST requests should include prior therapy history showing failure, intolerance, or contraindication to preferred agents.
• B/D (Part B vs Part D) entries may require documentation describing the use and setting of the drug to determine correct benefit routing.

Formulary legend and documentation expectations

Formulary legend and documentation expectations — The formulary legend defines abbreviations (PA, QL, ST, HI, B/D, LA, NE, ED). Refer to the legend to interpret flags and follow the documentation expectations described in the formulary and on the plan website when submitting PA or exception requests.

• Legend examples: PA = Prior Authorization, QL = Quantity Limit, ST = Step Therapy, HI = Home Infusion, B/D = Part B vs Part D, LA = Limited Availability, NE = No Express Scripts.
• Tier definitions: T1–T5 with T5 = Specialty (30-day supply only).

Documentation for prior authorization

Documentation for PA — When PA is required, submit clinical documentation that supports medical necessity (diagnosis, prior treatments, dosing, expected duration). For Part B vs D determinations, include setting and use details as requested.

• Include prescriber's supporting statement and relevant clinical notes to expedite a PA decision.
• For B/D flagged drugs, indicate whether administration is in an outpatient/medical setting (Part B) or for outpatient pharmacy dispensing (Part D).

PA documentation for insulin supplies

PA documentation for insulin supplies and pen needles — Insulin delivery devices and pen needles listed in the formulary require prior authorization. Provide clinical justification and device necessity when submitting PA requests.

• Examples: assure id insulin safety syringes, BD pen needles, and other listed insulin supplies carry PA requirements.
• Supplies often require documentation of diabetes diagnosis and intended use.

Observe QL when dispensing

Observe quantity limits (QL) when dispensing — Pharmacies must adhere to the QL specified in each formulary entry at dispensing and claims adjudication. Dispensing beyond the QL may deny coverage or require a prior authorization/exception.

• QLs are enforced per period listed (e.g., per 30 days, per 28 days, per 365 days) — follow the period indicated for each product.
• Examples: many psychiatric and cardiovascular agents have explicit per‑30‑day QLs.

Quantity limit adherence

Quantity limit adherence — Providers and pharmacies must ensure prescribed quantities align with formulary QLs or obtain a PA/exception. Exceeding QL without authorization can trigger denials and may require appeals.

• Where QL is specified (EA, ML, GM), ensure the unit and period match the formulary entry before dispensing.
• Requests to exceed QL should include justification and supporting clinical documentation.

PA / QL documentation requirement

PA/QL documentation requirement — For drugs marked PA and/or QL, the plan requires submission of supporting clinical documentation with the authorization request. This may include diagnosis codes, prior therapy history, lab results, or other evidence of medical necessity.

• Specialty products often require more extensive documentation and may need ongoing authorization for refills.
• Home infusion or Part B routed drugs require documentation specific to setting and administration.

PA documentation guidance

PA documentation — Provide concise, targeted clinical information with PA requests to avoid delays. Include prior medication trials (for ST), reason for selecting non‑formulary therapy (for exceptions), and anticipated duration of therapy.

• For expedited requests, ensure prescriber's statement clearly documents the clinical urgency to meet the 24‑hour review timeline.
• Attach relevant office notes, labs, or specialty consults as needed.

Documentation and routing note

Documentation and routing note — Use the formulary legend and product flags to determine correct benefit routing and required documentation: B/D (Part B vs Part D), HI (Home Infusion), NE (No Express Scripts), LA (Limited Availability). Submitting correct supporting information prevents miscoding and routing delays.

• B/D items may require physician attestation of setting/use.
• HI items may be coordinated through home infusion providers and require separate documentation.

Formulary requirement types

Formulary requirement types — The formulary uses several requirement codes (PA, QL, ST, HI, B/D, ED, LA, NE). Providers must consult the legend and the individual drug entry to determine what is required and submit the appropriate documentation for coverage consideration.

• PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; HI = Home Infusion; B/D = Part B vs Part D; ED = Excluded Drug; LA = Limited Availability; NE = No Express Scripts.
• Tier 5 designation indicates specialty tier and 30‑day supply restrictions.

Step therapy presence and note

Step therapy presence noted — Step therapy (ST) appears throughout the formulary legend and in multiple drug entries; where ST is indicated, members must try specified first‑line drugs before coverage of alternatives is considered. Specific step requirements are shown on product entries or in the plan's prior authorization/step therapy policy documents online.

• ST is listed in the legend and appears on product-level entries (e.g., DIFICID, FETZIMA, paliperidone ER, calcitriol external).
• Detailed ST steps and requirements are available in the plan's PA/ST documents on the website or by request.

Step Therapy Requirements

Step therapy requirements — Where 'ST' is indicated, the formulary or prior authorization policy will specify required trials or criteria. Prescribers should document prior medication trials, reasons for failure or intolerance, and any contraindications when requesting an override or exception.

• Examples with ST: FETZIMA (ST; QL), paliperidone ER (ST; QL), calcitriol external (ST).
• Requests to waive ST should include documentation of prior treatment failure, intolerance, or clinical rationale.

Step therapy notation and ophthalmic examples

Step therapy mentioned and notation — The formulary legend includes ST and individual product entries include ST notation where applicable. For certain ophthalmic anti‑inflammatories (difluprednate, loteprednol), ST is applied.

• Ophthalmic ST examples: difluprednate (ST), loteprednol (ST).
• Refer to product entry and the plan's ST documentation for the specific required trial sequence.