Prior Authorization Required — prescribers must obtain PA for certain drugs

Priority Health requires prior authorization (PA) for many medications — especially specialty, high-cost, oncology, certain GLP‑1 agents, insulin supplies, hormonal agents, and items flagged with HI (home infusion) or LA (limited availability). Prescribers must obtain approval before dispensing; drugs filled without an approved PA may be denied.

• PA applies broadly to Tier 5 (Specialty) drugs — Tier 5 items are 30-day supply only.
• Oncology agents frequently require both PA and Quantity Limits (QL); many oral and injectable oncology drugs in the formulary are labeled PA; QL (examples: lenalidomide, pomalidomide, VERZENIO, VITRAKVI, MEKINIST, NERLYNX).
• Selected GLP‑1s and related glycemic agents require PA and have QLs (examples: MOUNJARO, OZEMPIC — see QL per 28/30‑day periods).
• Insulin administration supplies and pen needles are flagged PA (examples: assured insulin syringes, pen needles such as embecta and bd pen needles).
• Specialty hormonal agents require PA (examples: NORDITROPIN, OMNITROPE, certain leuprolide and depot products).
• Home infusion (HI) and Limited Availability (LA) flags may trigger PA and special handling — drugs noted with HI often require coordination with infusion/home health services (examples: daptomycin, aztreonam, certain IV antibiotics).
• Many specialty biologics and immunomodulators are PA; quantity limits are commonly applied (examples: adalimumab products, ustekinumab, XOLAIR — PA and QL shown).

Exception request documentation and PA documentation expectations

Provide supporting clinical documentation when requesting PA, exceptions, or step‑therapy overrides. For Part B vs Part D determinations, prescribers may need to submit physician statements describing the use and setting of the drug.

• Exception requests: prescriber must explain medical rationale and submit supporting clinical statement; standard decisions are made within 72 hours of receiving the prescriber’s statement; expedited decisions within 24 hours when clinically warranted.
• PA documentation should describe diagnosis, prior therapies tried (when applicable), dosing, intended duration, and location of administration (inpatient/infusion vs outpatient).
• For formulary/tiering exceptions: include why alternatives are ineffective or cause adverse effects. Expect requests to reference the formulary page and last updated date.
• Required documentation for topical anesthetics and lidocaine products: PA and QL units must be documented on the request (examples: lidocaine patch and LIDOCAN products flagged PA; QL = 90 EA per 30 days).

Document QL values on requests; quantity‑limit documentation required

When submitting PA or claims, include exact Quantity Limit (QL) units and clinical justification for any request exceeding QL. Failure to document QL units or to meet PA/ST/QL requirements can result in denial of coverage.

• Document the requested QL (e.g., mL, EA, GM) on the PA form or claim to support benefit determination.
• If requesting quantities above the listed QL, include clinical rationale explaining medical necessity and expected duration.
• PA and QL frequently co-occur for injectable and specialty agents — omission of QL info or supporting clinical notes increases denial risk.
• Examples of PA/QL pairs in the formulary: XIFAXAN (PA; QL 9 EA per 30 days for 200 mg; 60 EA per 30 days for 550 mg), many oncology agents (e.g., VERZENIO, VENCLEXTA — PA and specific QL), and biologics/immunomodulators (e.g., adalimumab products — PA; QL ml/28 days).
• Enoxaparin and other parenteral anticoagulants have specific QLs that must be included on claims (examples: enoxaparin prefilled syringes QL per 30 days).

Step Therapy Requirement — members may need to try alternatives first

Step therapy (ST) is used for selected agents across classes; when ST is required, prescribers must show that required first‑line agents were tried and either failed or were not tolerated before PA for the subsequent agent will be approved.

• ST is indicated in the formulary legend and applied to specific drugs (examples: DIFICID, FETZIMA, vilazodone, paliperidone ER products).
• For ophthalmic agents, some products (difluprednate, loteprednol, travoprost bak‑free) are flagged ST — document prior therapy per ST requirements.
• When ST applies, include dates and outcomes of prior therapies in the PA or exception request to expedite review.
• The formulary includes an ST legend; specific step sequences are defined per drug entry (refer to formulary pages for details).

Prior authorization triggers and denial risk

Utilization management triggers that commonly lead to PA include specialty tiering, oncology agents, home infusion (HI) items, LA (limited availability), and listed high‑cost drugs. Expect denials if PA, QL, or ST requirements are not met.

• PA/QL denials: many specialty and oncology drugs have both PA and QL — lack of approved PA or exceeding QL without justification may result in denial.
• Home infusion trigger: drugs labeled HI require coordination with appropriate infusion services and may need additional documentation; claims without required arrangements risk denial.
• Tier 5 specialty drugs are subject to PA and often limited to a 30‑day supply; ensure PA is obtained before dispensing.
• Examples where PA/QL may trigger denial: tolvaptan (PA; QL), FASENRA (PA; QL), XIFAXAN (PA; QL), and many oncology products listed in the formulary.
• Formulary abbreviations (B/D, PA, QL, ST, HI, LA, NE) are on the legend — follow them when preparing requests.