Priority Health Medicare Formulary Coverage Update

Formulary Coverage and Access

Covered when ALL of the following are met:

Standard Coverage Conditions: The drug is listed on the Priority Health Medicare formulary, is medically necessary for the member, is filled at a Priority Health Medicare network pharmacy (or per plan directions), and all applicable plan rules are followed (e.g., PA, QL, ST as listed).

See formulary definition and coverage rules.

Circumstances permitting immediate formulary changes: Immediate substitution or removal may occur when adding a generic or certain interchangeable biosimilars, when a drug is withdrawn from the market by the manufacturer, or when the FDA withdraws a drug for safety/effectiveness reasons.

Plan may immediately add interchangeable biosimilars and change tiering or remove reference biologic; immediate removals for market withdrawal or FDA action.

Utilization management requirements: If the drug entry lists Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Home Infusion (HI), Limited Availability (LA), Part B vs Part D (B/D) or other requirement flags, those requirements must be satisfied for coverage; failure to obtain required PA or exceed QL may result in non-coverage or denial.

Providers must follow PA/QL/ST rules as listed; PA required before filling for listed drugs.

Exception process: Members or prescribers may request an exception to cover a non‑formulary drug or to waive a restriction (PA, ST, QL) or to request lower cost‑sharing; prescriber must provide medical rationale and supporting statement; standard decision timeframe is 72 hours (24 hours for expedited requests).

Prescriber’s supporting statement required; timelines: 72 hours standard, 24 hours expedited.

Transition and temporary supply rules: For new or continuing members, Priority Health Medicare may provide a temporary supply (generally a 30‑day supply) while an exception or transition is pursued; long‑term care residents may receive a 31‑day emergency supply under specified conditions.

Temporary supplies up to 30 days while exception pursued; 31‑day emergency supply for long‑term care residents when applicable.

The formulary legend defines ED (Excluded Drug) as a prescription that is not normally covered in a Medicare Prescription Drug Plan. Amounts paid by the member for an ED do not count toward total drug costs

Because EDs are not generally covered by the plan, filling an ED may result in non-coverage or out-of-pocket expense unless the drug is specifically covered on the member’s plan variant.

Excluded Drugs (ED) are identified in the formulary legend and are described as drugs that the Medicare Prescription Drug Plan generally does not cover. The policy notes that payments for EDs do not contribute to the member’s total drug costs and that members receiving Extra Help will not receive assistance for EDs except on the Priority Medicare® Thrive and Thrive Plus plans.

Providers should confirm plan-specific coverage before dispensing an ED and follow the exception request process if coverage is being sought for a drug that is otherwise excluded.

The formulary states that Tier 5 (Specialty) drugs are limited to a 30-day supply only. This supply limitation is noted repeatedly in the legend and on specialty-drug listings throughout the formulary extract.

When prescribing or dispensing Tier 5 medications, prescribers and pharmacists should expect the plan to enforce a 30-day supply maximum and plan accordingly for refills or prior authorization requests that might request an exception to supply duration.

The document legend and multiple drug-list pages reiterate the policy that Tier 5 (Specialty) drugs are 30‑day supply only. This is a plan-level supply restriction that applies to specialty-tier entries across the formulary.

Clinical and billing workflows should account for this 30‑day supply rule when submitting claims or authorizations for Tier 5 products to avoid processing delays or denials.

Within the provided excerpt there are no line‑item drug entries that are explicitly listed as excluded beyond the abbreviation entry in the legend. The legend defines ED, but specific drugs identified as ED do not appear in these pages of the extract.

If an excluded drug is being considered for coverage, follow the formulary’s exception process and verify plan variant coverage (for example, Thrive or Thrive Plus) as noted in the legend.

The formulary legend and multiple drug-list sections consistently state that Tier 5 (Specialty) drugs are limited to 30-day supply only. This appears as a universal note associated with the specialty tier across pages of the formulary.

Operational processes — prior authorization submissions, refill scheduling, and member counseling — should reflect the 30‑day supply cap for Tier 5 items to ensure compliance with plan requirements.

The pages in this extract do not list any blanket or comprehensive exclusion lists. The legend includes the ED (Excluded Drug) abbreviation, but specific excluded drugs are not present on these pages.

Providers should consult the full formulary or contact Customer Care for any questions about whether a particular drug is designated as an excluded drug under the member’s plan.

Across the formulary extract, the document repeats the operational rule that Tier 5 drugs are 30‑day supply only. This supply restriction is part of the tier definitions in the legend and accompanies specialty‑tier entries.

Prior authorization requests and dispensing workflows for Tier 5 medications should therefore assume a 30‑day maximum supply unless an approved exception states otherwise.

The fragment provided does not include explicit excluded‑drug line items. It does, however, show Tier 5 biologic entries with their associated requirements (e.g., PA and QL) and repeats the Tier 5 = 30‑day supply only note in the legend.

For exclusion determinations, refer to the complete formulary or contact plan support; the legend alone identifies the concept of ED but does not enumerate excluded agents in this excerpt.

In this excerpt no specific excluded drugs are listed; the legend includes abbreviations such as ED and NE (No Express Scripts), but individual ED annotations are not present on the sample pages.

When an ED designation is suspected for a given product, confirm coverage by checking the complete formulary, plan variant rules, or contacting Customer Care before dispensing to the member.

Formulary Codes, Abbreviations & Drug Listings

Formulary Abbreviations / Codesmixed

T1	Preferred generic
T2	Generic
T3	Preferred brand
T4	Non-preferred drug
T5	Specialty
B/D	Part B vs. Part D
EA	Each
ED	Excluded Drug
HI	Home Infusion
LA	Limited Availability

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Selected drugs with tier and requirement notesmixed

bupropion hcl er (xl)	Drug Tiers = 2; Requirements/Limits = .
citalopram hydrobromide oral tablet 10 mg, 20 mg	Drug Tiers = 1; Requirements/Limits = QL (45 EA per 30 days).
escitalopram oxalate oral tablet	Drug Tiers = 2; Requirements/Limits = .
fluoxetine hcl oral capsule	Drug Tiers = 1; Requirements/Limits = .
mirtazapine oral tablet 15 mg, 30 mg, 45 mg	Drug Tiers = 2; Requirements/Limits = .
ondansetron hcl oral tablet 4 mg, 8 mg	Drug Tiers = 2; Requirements/Limits = B/D.
aprepitant	Drug Tiers = 4; Requirements/Limits = PA; QL (6 EA per 30 days).
ibuprofen oral tablet 400 mg, 600 mg, 800 mg	Drug Tiers = 2; Requirements/Limits = .
diclofenac sodium oral tablet delayed release 50 mg, 75 mg	Drug Tiers = 2; Requirements/Limits = .
celecoxib oral	Drug Tiers = 2; Requirements/Limits = .

Sample specialty drug listingsmixed

AUVELITY	Drug Tiers = 5; Requirements/Limits = PA; QL (60 EA per 30 days); NE.
EXXUA	Drug Tiers = 5; Requirements/Limits = PA; QL (30 EA per 30 days).
EPIDIOLEX	Drug Tiers = 5; Requirements/Limits = PA; QL (500 ML per 30 days).
FINTEPLA	Drug Tiers = 5; Requirements/Limits = PA; QL (360 ML per 30 days).
DIFICID ORAL SUSPENSION RECONSTITUTED	Drug Tiers = 5; Requirements/Limits = ST; QL (136 ML per 10 days).
LENVIMA	Drug Tiers = 5; Requirements/Limits = PA; QL (varies by dose); LA.
LYNPARZA ORAL TABLET	Drug Tiers = 5; Requirements/Limits = PA; QL (120 EA per 30 days).
TAGRISSO	Drug Tiers = 5; Requirements/Limits = PA; QL (30 EA per 30 days); LA.
IMBRUVICA ORAL TABLET	Drug Tiers = 5; Requirements/Limits = PA; QL (30 EA per 30 days).
TRIKAFTA ORAL TABLET THERAPY PACK	Drug Tiers = 5; Requirements/Limits = PA; QL (84 EA per 28 days).

Drug tier and requirement entries (no procedure codes)mixed

enoxaparin sodium injection solution prefilled syringe 30 mg/0.3ml	Drug Tiers = 4; Requirements/Limits = QL (18 ML per 30 days).
warfarin sodium oral	Drug Tiers = 1; Requirements/Limits = .
XARELTO ORAL TABLET 10 MG, 20 MG	Drug Tiers = 3; Requirements/Limits = QL (30 EA per 30 days).
eltrombopag olamine oral tablet 50 mg, 75 mg	Drug Tiers = 5; Requirements/Limits = PA; QL (60 EA per 30 days).
everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg	Drug Tiers = 5; Requirements/Limits = PA; QL (30 EA per 30 days).
adalimumab-adaz subcutaneous solution auto-injector 40 mg/0.4ml	Drug Tiers = 5; Requirements/Limits = PA; QL (2.4 ML per 28 days).
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE 40 MG/0.8ML	Drug Tiers = 5; Requirements/Limits = PA; QL (2 EA per 28 days).
REPATHA	Drug Tiers = 3; Requirements/Limits = PA; QL (2 ML per 28 days).
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML	Drug Tiers = 5; Requirements/Limits = PA; QL (8 ML per 30 days).
SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE 360 MG/2.4ML	Drug Tiers = 5; Requirements/Limits = PA; QL (2.4 ML per 56 days).

Formulary abbreviations & unitsmixed

EA	Each
ML	Milliliters
GM	Grams
QL	Quantity Limits
PA	Prior Authorization
ST	Step Therapy
B/D	Part B vs. Part D

Drug strengths and QL notationsmixed

morphine sulfate er oral tablet extended release 100 mg	Drug Tiers = 4; Requirements/Limits = QL (60 EA per 30 days).
morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg	Drug Tiers = 4; Requirements/Limits = QL (120 EA per 30 days).
oxymorphone hcl er	Drug Tiers = 4; Requirements/Limits = QL (90 EA per 30 days).

Formulary drug entries (partial list)mixed

pregabalin oral capsule 100 mg, 150 mg, 200 mg	Drug Tiers = 3; Requirements/Limits = QL (90 EA per 30 days).
duloxetine hcl oral capsule 60 mg	Drug Tiers = 2; Requirements/Limits = QL (60 EA per 30 days).
rosuvastatin calcium oral tablet 10 mg, 5 mg	Drug Tiers = 1; Requirements/Limits = QL (120 EA per 30 days).
atorvastatin calcium oral tablet 10 mg	Drug Tiers = 1; Requirements/Limits = QL (240 EA per 30 days).
simvastatin oral tablet 10 mg, 20 mg, 5 mg	Drug Tiers = 1; Requirements/Limits = QL (120 EA per 30 days).
metoprolol tartrate oral tablet 25 mg, 50 mg, 100 mg	Drug Tiers = 1; Requirements/Limits = .
propranolol hcl oral tablet	Drug Tiers = 1; Requirements/Limits = .
nebivolol hcl	Drug Tiers = 4; Requirements/Limits = .
amlodipine besylate oral	Drug Tiers = 1; Requirements/Limits = .
losartan potassium-hctz oral tablet 100-12.5 mg	Drug Tiers = 1; Requirements/Limits = QL (30 EA per 30 days).

Formulary requirement abbreviationsmixed

PA	Prior Authorization
QL	Quantity Limits
ST	Step Therapy
NE	No Express Scripts
B/D	Part B vs. Part D

Examples of listed drug presentationsmixed

oral tablet	Common oral solid dosage form
oral solution	Liquid oral formulation (mL-based QL)
subcutaneous solution prefilled syringe	Injectable biologic presentation (ML-based QL)
ophthalmic solution	Eye drop formulations (ML/GM QL)

Formulary utilization codes and examplesmixed

QL (EA per 30 days)	Quantified maximum units per 30-day period - examples throughout formulary.
QL (ML per 30 days)	Liquid volume limits per 30 days (e.g., 300 ML).
PA	Prior authorization required for select specialty or high-cost drugs.
ST	Step therapy applies to indicated products (see individual entries).

Quantity limits examples (selected items)mixed

DIFICID ORAL SUSPENSION RECONSTITUTED	QL (136 ML per 10 days).
morphine sulfate er 100 mg	QL (60 EA per 30 days).
ibuprofen oral solution 100 mg/5ml	Listed as Tier 4 with no specific QL noted in section.

Quantity limits examples (additional)mixed

brivaracetam oral solution	PA; QL (600 ML per 30 days).
memantine hcl oral solution 2 mg/ml	QL (300 ML per 30 days).
citalopram hydrobromide oral solution	QL (600 ML per 30 days).

Quantity Limits examples (extended list)mixed

clonazepam oral tablet 0.5 mg, 1 mg	QL (90 EA per 30 days).
clonazepam oral tablet 2 mg	QL (300 EA per 30 days).
diazepam oral solution 5 mg/5ml	QL (1200 ML per 30 days).
pregabalin oral capsule	QL (90 EA per 30 days).
rosuvastatin 10 mg	QL (120 EA per 30 days).
atorvastatin 10 mg	QL (240 EA per 30 days).
simvastatin 10/20/5 mg	QL (120 EA per 30 days).
ticagrelor	Not listed here; see full formulary.

Quantity Limits examples (small set)mixed

invega sustenna prefilled syringe 117 mg/0.75ml	QL (0.75 ML per 30 days).
invega sustenna 78 mg/0.5ml	QL (0.5 ML per 30 days).

Example quantity limits (varied units)mixed

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML	QL (4 ML per 28 days).
DUPIXENT 300 MG/2ML	QL (8 ML per 30 days).
REPATHA PUSHTRONEX SYSTEM	QL (3.5 ML per 30 days).

Quantity limits examples (enoxaparin, XARELTO)mixed

enoxaparin sodium injection prefilled syringe 60 mg/0.6ml	QL (36 ML per 30 days).
XARELTO ORAL SUSPENSION RECONSTITUTED	QL (620 ML per 30 days).

Example quantity limits (multiple statin/other entries)mixed

atorvastatin 40 mg	QL (60 EA per 30 days).
atorvastatin 80 mg	QL (30 EA per 30 days).
rosuvastatin 40 mg	QL (30 EA per 30 days).

Common QL valuesmixed

30 EA per 30 days	Common monthly unit limit for many oral therapies.
60 EA per 30 days	Common two-month-equivalent monthly limit for higher-dose regimens.
ML per 30 days	Used for liquids and injectables (e.g., 300 ML).

Example quantity limits (varied examples)mixed

DIFICID ORAL TABLET	QL (20 EA per 10 days).
PAXLOVID (150/100)	QL (40 EA per 180 days).
epinephrine auto-injector	QL (4 EA per 30 days).

Quantity Limits for biologics (ENBREL, HUMIRA, OTEZLA)mixed

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML	QL (8 ML per 28 days).
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML	QL (2 EA per 28 days).
OTEZLA ORAL TABLET 20 MG	Drug Tiers = 5; Requirements/Limits = PA; QL (60 EA per 30 days).

Ophthalmic/other QL examplesmixed

gatifloxacin ophthalmic	Listed without specific QL in section.
tobramycin ophthalmic	QL (30 ML per 30 days).
budesonide inhalation suspension 0.25 mg/2ml	Requirements/Limits = B/D.

Prescriber & Provider Requirements

Prior Authorization
Prior Authorization Required
Priority Health Medicare requires prior authorization (PA) for many listed drugs, including numerous specialty, high-cost, infusion, and select non-preferred products. Providers or prescribers must obtain approval from Priority Health Medicare before dispensing these drugs; failure to obtain PA may result in denial of coverage. PA requirements are indicated in the formulary by the PA flag and appear alongside Quantity Limits (QL), Step Therapy (ST), Home Infusion (HI), Part B vs Part D billing designations (B/D), Limited Availability (LA), No Express Scripts (NE), and Excluded Drug (ED) flags.
PA applies to many listed agents (examples in formulary: lidocaine patch products, XIFAXAN, select anticonvulsants, specialty oncology products, biologics and injectables).
PA applies to many specialty drugs and injectables (examples: COSENTYX, DUPIXENT, SKYRIZI, DUPIXENT, HUMIRA, REPATHA, TRIKAFTA, CFTR modulators, and many others listed in the formulary).
Some antifungals and emetogenic adjuncts require PA or are billed under Part B (B/D), e.g., ABELCET (B/D), amphotericin B (B/D), aprepitant (PA; QL).

Prior Authorization
Prior Authorization — Summary
Summary: consult the formulary for specific PA flags and requirement details (PA, QL, ST, HI, B/D). The formulary lists drug-specific requirements and limits (PA, QL, ST) beside each product. Tier 5 (specialty) drugs are often PA and limited to 30-day supply unless otherwise noted.
Tier 5 (Specialty) drugs are typically 30-day supply only and often require PA.
PA flags in formulary rows indicate where prior authorization is required; QL and ST flags may accompany PA.

Prior Authorization
Prior authorization required for listed agents (examples)
Examples of listed agents requiring PA (representative, not exhaustive). Providers should verify PA requirements for the specific NDC/formulation prior to dispensing.
Lidocaine external patch/ointment (PA; QL noted for certain lidocaine products).
XIFAXAN (PA; QL for 200 mg and 550 mg listed).
Linezolid IV/oral preparations (PA or QL as indicated).

Prior Authorization
Prior authorization required for listed specialty drugs (examples)
Examples of specialty drugs requiring PA (representative list from formulary). Many biologics, injectables, and specialty oral agents are designated PA and QL.
Anticonvulsant specialty agents: BRIVARACETAM, EPIDIOLEX, FINTEPLA (PA; QL).
Biologics and injectable specialty products: COSENTYX, DUPIXENT, SKYRIZI, DUPIXENT pen/syringe and other prefilled injectables (PA; QL).
JAK inhibitors and other specialty or high-cost orals: XELJANZ, RINVOQ, many oncology agents (PA; QL).

Prior Authorization
Antifungals / Emetogenic adjuncts — PA examples
Antifungals and emetogenic adjuncts: certain agents require PA or are billed under Part B. Check the formulary row for B/D or PA flags and any Quantity Limits.
Antifungals with B/D designation: ABELCET, amphotericin B products (B/D).
Emetogenic adjuncts: aprepitant (PA; QL), dronabinol (B/D; QL), and ondansetron products (B/D).
When B/D appears, the billing pathway (Part B vs Part D) and documentation of setting/use may be required.

Prior Authorization
Prior Authorization requirements — many specialty drugs
Many specialty and high-cost drugs in the formulary require prior authorization. This includes biologics, specialty injectables, specialty oral therapies, enzyme replacements, CFTR modulators, and other limited-availability products. Providers must confirm PA and QL prior to dispensing.
Oncology oral agents and kinase inhibitors often show PA and QL flags (e.g., KISQALI, LUMAKRAS, LYNPARZA).
CFTR modulators and cystic fibrosis therapies: TRIKAFTA, KALYDECO, ORKAMBI (PA; QL as noted).
Many specialty biologics: DUPIXENT, COSENTYX, SKYRIZI, USTEKINUMAB, HUMIRA, etc. (PA; QL).

Prior Authorization
Prior authorization required for listed drugs (brand/specialty examples)
Examples of selected brand or specialty drugs with PA requirements. Always check the formulary for the exact formulation and QL.
Aripiprazole oral solution and dispersible formulations: PA; QL for liquid formulations.
Injectable long-acting antipsychotics (e.g., ABILIFY MAINTENA, INVEGA products) include QL and some PA requirements.
Paliperidone ER formulations: ST and QL apply for specific strengths.

Prior Authorization
Prior authorization — selected products
Selected products across the formulary require prior authorization; examples include injectables, specialty pens/cartridges, and select oral specialty agents. Check each row for PA and QL notation.
GLP-1 and other injectable diabetes/weight-loss agents (OZEMPIC, TRULICITY, MOUNJARO) — PA; QL specified.
Many insulins and insulin supplies (pen needles, syringes) show PA requirements for specific SKUs.
Some autoimmune biologics and specialty injectables (REPATHA, PRINIV, etc.) require PA.

Prior Authorization
Prior authorization required for listed specialty/selected drugs
Prior authorization is required for numerous listed specialty and selected drugs throughout the formulary. Providers should verify PA and QL before prescribing or dispensing to avoid claim denials.
Blood product modifiers and specialty hematology agents (e.g., Eltrombopag — PA; QL).
Erythropoiesis agents and specialty injectables (PROCRIT, RETACRIT) may have B/D and PA designations.
Many TNF and other biologic biosimilars/sourcing variants carry PA flags and QL limits.

Prior Authorization
Prior authorization required for listed specialty/brand drugs (examples)
Additional specialty/brand examples requiring PA are included throughout the formulary. Providers must check the formulary entry for the specific product, strength, and route to determine PA and QL applicability.
Monoclonal antibodies and subcutaneous biologics (COSENTYX, DUPIXENT, SKYRIZI, USTEKINUMAB) — PA; QL noted per mL or per dosing period.
Specialty autoimmune and dermatology injectables — PA; QL typically shown in mL per 28/30/56 days.
XELJANZ and other high-cost oral immunomodulators — PA; QL.

Prior Authorization
Prior Authorization requirement present
Presence of a PA flag in the formulary is an authorization trigger — prescribers must submit supporting clinical information. PA may interact with other utilization management flags (ST, QL, HI, B/D) and can trigger additional documentation or coverage determinations.
If PA is required, submit clinical rationale and prior treatments tried (if applicable) to support medical necessity.
PA combined with ST or QL may require documentation that step therapy was met or that additional quantities are clinically justified.
HI or B/D designations may require site-of-care or setting documentation (e.g., infusion in home vs. outpatient).

Denial Risk
PA/QL may trigger denial if not met
Failure to meet PA or QL requirements may result in claim denial. Providers should confirm PA approval before dispensing to mitigate financial risk to the member.
Claims for drugs requiring PA that are dispensed without approval are at risk for denial.
Denial risk increases when PA is accompanied by other flags (QL, ST, HI, B/D).

Note
Prior authorization triggers
PA triggers: the PA, QL, ST, HI, B/D, LA, NE, and ED flags appearing in the formulary indicate where authorizations, billing-pathway decisions, or additional documentation are required. Review each product row for these flags.
B/D indicates Part B vs Part D billing pathway — supporting use/setting information may be required from the prescriber.
HI indicates potential medical benefit/home infusion; documentation of infusion setting and clinical need may be required.
NE indicates product is not available through Express Scripts; alternate fulfillment steps may be necessary.

Note
Quantity limits enforced
Formulary rows listing PA drugs (especially specialty agents) should be checked for Quantity Limits (QL). QLs are enforced and may restrict supplied amount per fill period.
Examples: COSENTYX QL per 28 days; DUPIXENT QL per 30 days; many oral oncology agents have per-cycle QLs.
Quantity limits are noted in the formulary entry (e.g., 'QL (60 EA per 30 days)' or 'QL (3 ML per 28 days)').

Denial Risk
Triggers for denial or additional requirement
Triggers for denial or additional requirements include absence of PA approval, failure to meet step therapy, exceeding quantity limits, insufficient documentation for B/D or HI designations, and dispensing excluded drugs (ED). Providers should proactively supply required documentation to avoid delays or denials.
ED flag indicates excluded drug — coverage may not apply under the Part D plan (limited exceptions for specific plan variants).
If QL is exceeded, prior authorization or exception may be required to cover additional quantity.
For B/D items, prescribers may need to document the clinical setting or intent (medical benefit vs pharmacy benefit) to determine coverage.

Documentation Required
Exception Request Documentation guidance
Exception requests and supporting documentation: prescribers must provide clinical rationale when requesting exceptions to PA, QL, ST, or formulary tiering. Priority Health Medicare typically decides within 72 hours of receiving the prescriber's supporting statement; expedited (24-hour) review is available when waiting could seriously harm the member.
Exception requests can ask to waive PA, ST, or QL or to cover a non-formulary drug or place a formulary drug on a lower cost-sharing tier (subject to specialty tier rules).
Prescriber's supporting statement should explain medical necessity, prior therapies tried, and why the formulary alternative(s) are not appropriate.
Standard decision time is 72 hours; expedited requests require agreement that delay could seriously harm the member and will be decided within 24 hours after receipt of the prescriber's supporting statement.

Documentation Required
Examples of documentation-backed PA/QL
Examples of documentation that commonly support PA/QL approvals: medical history, prior treatment trials and dates, diagnostic test results, clinical notes demonstrating failure or intolerance to formulary alternatives, and specialty-specific lab values or genetic testing when relevant.
Psychotropic and neurology agents: documentation of prior agents tried, dosing history, and response or adverse effects (e.g., aripiprazole formulation differences).
Oncology and specialty agents: relevant tumor/genetic markers, prior lines of therapy, and dosing cycle plan.
Hematology and biologics: diagnosis, prior therapies, platelet counts or other relevant labs for eltrombopag, and therapy intent.

Documentation Required
Documentation for durable medical supplies and insulins
Documentation expectations for durable medical supplies, insulins, and related accessories: the formulary marks many supplies and insulin-related items as PA. Providers must include clinical justification and, when applicable, prescription details matching the supplied device.
Insulin pen needles, syringes, and certain insulin devices are flagged PA — include prescription details and clinical need.
Durable medical supplies (e.g., gauze, infusion supplies) may also require PA and supporting clinical documentation.
For home infusion (HI) products, include site-of-care justification and infusion plan.

Documentation Required
Documentation expectations for PA
General documentation expectations: provide clear, specific clinical information aligned to the PA criteria — diagnosis, prior therapies, lab results, and intended dosing/administration setting. Use the formulary entry indicators (B/D, HI, ST, QL) to determine what additional documentation is necessary.
When HI is indicated, include site-of-care and infusion details.
When B/D is indicated, include the clinical setting and rationale for Part B billing if applicable.
For ST, include documentation of trials and failures or contraindications to the required first-line agents.

Note
Documentation and abbreviations — provider reminder
Documentation & abbreviations reminder: review the formulary abbreviation key (pages indicated) — B/D (Part B vs Part D), PA (Prior Authorization), QL (Quantity Limit), ST (Step Therapy), HI (Home Infusion), NE (No Express Scripts), ED (Excluded Drug). Provide documentation aligned with these flags to facilitate timely review.
Use the formulary abbreviations to interpret requirements and gather the correct supporting documentation.
For B/D items, clinical use and setting information from the prescriber is often required to determine coverage pathway.

Billing Rule
Billing pathway note (B/D designation)
Billing pathway note: B/D designation indicates this drug may be billed under Medicare Part B or Part D depending on clinical use and setting. Providers should submit documentation describing the use and site of administration so Priority Health Medicare can determine the correct billing pathway.
When B/D appears next to a product, provide prescriber documentation on indication and setting (e.g., outpatient infusion vs pharmacy-dispensed therapy).
Some infusion and parenteral nutrition products are B/D and may require coordination with medical benefit prior authorization.

Documentation Required
Supply supporting documentation for PA/QL
Supply supporting documentation for PA/QL: when requesting PA for supplies or increased quantities, include product-specific prescriptions, clinical rationale, and any relevant measurements or device requirements.
For ophthalmic QL exceptions or PA (e.g., trifluridine, natacyn), include clinical notes supporting need for quantity beyond the QL.
For specialty supply kits or injectors, include the exact SKU, required dosing schedule, and clinical justification.

Documentation Required
Required documentation for PA/QL
Required documentation for PA/QL or exceptions may include prescriber statement, medical records, prior authorization forms, lab or imaging results, and notes on prior therapy attempts. Ensure submitted documentation aligns with the clinical criteria for the requested drug.
Include dates and outcomes of prior medication trials when relevant to ST or PA criteria.
For durable medical supplies and infusions, include care plan and infusion orders where applicable.
Complete and accurate documentation speeds review and reduces denial risk.

Note
Quantity limits and utilization notes for providers
Quantity limits and utilization notes for providers: the formulary indicates QL for many agents (e.g., XARELTO 30 tablets per 30 days; specialty biologics with mL-per-period limits). If clinical need exceeds the published QL, submit a PA/exception request with supporting documentation.
Examples: XARELTO oral tablet 10 mg — QL (30 EA per 30 days); many specialty injectables specify mL or EA per 28/30/56/365 days.
When requesting quantities above QL, include dosing schedule, indication, and clinical rationale.
Quantity limits are enforced even when PA is in place unless an exception is approved.

Step Therapy
Step Therapy Requirement
Step Therapy Requirement: Step therapy (ST) applies to certain agents; members may be required to try and fail specified first-line drugs before a non-preferred agent is covered. ST flags appear in formulary rows and must be satisfied or bypassed via an exception.
Examples: DIFICID oral formulations (ST; QL), FETZIMA, TRINTELLIX, vilazodone (ST; QL) and other antidepressants noted in formulary.
When ST applies, prescribers should document prior trials and reasons for failure/intolerance to meet PA/exception requirements.
ST may be referenced in the formulary legend; see the formulary for details on required step(s).

Step Therapy
Step Therapy — summary
Step Therapy — summary: ST flags indicate a required trial of formulary-preferred therapy before coverage of the requested drug. Providers must document prior therapy attempts or request an exception when clinically warranted.
Paliperidone ER formulations have ST requirements for initiation of some strengths.
Some ophthalmic agents (difluprednate, loteprednol) and other classes reference ST in the formulary legend or individual rows.
If ST is present, include documentation of trials, dates, and outcomes when submitting PA or exceptions.

Step Therapy
Step therapy referenced
Step therapy references in the formulary legend and specific drug rows indicate where ST applies. Providers should consult the legend and the product row for details on required step agents and any exceptions pathways.
The formulary legend (page references) explains ST and related abbreviations — review when a drug row lists ST.
Ophthalmic agents and certain topical steroids may reference ST in their requirements.
ST exceptions require prescriber documentation explaining why the required step agents are not appropriate.

Step Therapy
Step therapy for select agents
Step therapy for select agents: certain CNS, antidepressant, and other classes list ST or require trials of specific agents prior to coverage of non-preferred products.
FETZIMA, TRINTELLIX, vilazodone, and some newer antidepressants are subject to ST; see formulary entries for trial requirements.
DIFICID oral formulations list ST and specific QL limits.
When ST applies, documentation of prior medication trials and reasons for change is required for PA/exception review.

Step Therapy
Step therapy (not detailed)
Step therapy (not detailed in every row) may apply broadly across therapeutic classes. If ST appears in the formulary row, follow the documented step requirements or request an exception with supporting clinical evidence.
Some entries reference ST in the legend only — check the full formulary details or contact Customer Care for clarification.
ST requirements and allowable exceptions are determined case-by-case based on clinical documentation.

Step Therapy
Step therapy applies to specific agents
Step therapy applies to specific agents where noted (e.g., paliperidone ER). Providers must document that required step(s) were tried or submit a clinical justification for bypassing step therapy.
Paliperidone ER oral tablets: ST applies to certain strengths with specific QL.
Document prior trials with dates and outcomes to support PA when ST is present.

Step Therapy
Step therapy (reference)
Step therapy references in the formulary and legend guide provider action. If referenced, follow the step requirements or submit an exception request with documentation showing medical necessity.
Formulary legend explains ST and related abbreviations; use it to interpret row-level ST flags.
Exceptions to ST require prescriber supporting statement and may be expedited if clinically necessary.

Specified Quantity Limits (Selected Entries)

Step therapy action	How it works / provider action	Supporting formulary note
Require trial of a preferred drug(s) before covering alternatives (Step Therapy)	Prescriber must document prior trial and failure, intolerance, or contraindication to the preferred agent(s); submit supporting clinical information with prior authorization or exception request as appropriate.	Some drugs are subject to ST (Step Therapy). If Step Therapy applies, the member must try the specified preferred drug(s) before coverage of alternatives; exceptions may be requested.
DIFICID-specific step therapy	DIFICID oral formulations are listed with 'ST' — prescriber must meet step requirement and follow QL; request prior authorization if exception needed.	DIFICID entries include ST and associated QL values in the formulary.
Antidepressant agents (select) — ST applies	For agents such as FETZIMA, TRINTELLIX, and vilazodone, prescriber must document trial of preferred alternatives per ST; follow QL limits and submit PA/exception if indicated.	FETZIMA, TRINTELLIX, vilazodone are noted with ST and QL (e.g., 30 EA per 30 days) in the formulary.
Paliperidone ER formulations — ST applies	Prescriber must document failure or intolerance to required prior agent(s) before approval of certain paliperidone ER strengths; include clinical rationale in PA/exception request.	Some paliperidone ER strengths are listed with ST in the formulary legend/entries.
Ophthalmic agents — ST for selected products	For products such as travoprost (BAK-free), difluprednate, and loteprednol, prescriber must follow ST requirements indicated in the Requirements/Limits column; provide documentation when requesting exceptions.	At least one ophthalmic product (travoprost bak-free) and select ophthalmic anti-inflammatories (difluprednate, loteprednol) are flagged with ST in the formulary.
General exception process when ST cannot be met	If step therapy is inappropriate (e.g., clinical contraindication), prescriber may request an exception — include a supporting statement and relevant clinical documentation; expedited review timelines apply when eligible.	Members or prescribers may request exceptions to ST; prescriber must provide medical rationale and supporting documentation per formulary exception process.

XARELTO 10MG example QL

XARELTO 10 mg (oral tablet)QL 30 tablets per 30-day prescription (example)

XARELTO 15/2.5 mgQL 60 EA per 30 days

XARELTO oral suspension (reconstituted)QL 620 mL per 30 days

Unspecified example QL (30 per 30 days)

Unspecified examplee.g., 30 tablets per 30-day prescription (illustrative example)

Common month supplyMany tablet QLs expressed per 30 days

Units usedEA (each) commonly used for tablets

diclofenac sodium external solution 1.5% QL

diclofenac sodium external solution 1.5%QL 750 mL per 30 days

diclofenac oral formulationsVarious tiers; some with no QL

UnitML used for topical liquid QLs

fentanyl transdermal patch (72 hour) QL

fentanyl transdermal patch (72 hour)QL 10 EA per 30 days

opioid patches (general)Various QLs listed for extended-release opioids

UnitEA used for transdermal patches

methadone HCl oral solution QL

methadone HCl oral solution 10 mg/5 mLQL 600 mL per 30 days

methadone 5 mg/5 mLQL 1200 mL per 30 days (other strength)

methadone tabletsQL example: 90 EA per 30 days for 10 mg tablet

XIFAXAN 200 mg QL

XIFAXAN 200 mg (oral tablet)QL 9 EA per 30 days; PA required

XIFAXAN 550 mg (oral tablet)QL 60 EA per 30 days; PA required

vancomycin oral capsuleQL 160 EA per 30 days

XIFAXAN 550 mg QL

XIFAXAN 550 mgQL 60 EA per 30 days; PA required

XIFAXAN 200 mgQL 9 EA per 30 days; PA required

Related enteral antibioticsvancomycin oral QL example present

DIFICID oral suspension QL

DIFICID oral suspensionQL 136 mL per 10 days; ST and PA noted

DIFICID oral tabletQL 20 EA per 10 days; ST and PA noted

TierTier 5 for DIFICID formulations

DIFICID oral tablet QL

DIFICID oral tabletQL 20 EA per 10 days; ST applies

DIFICID oral suspensionQL 136 mL per 10 days; ST applies

TierListed as Tier 5

brivaracetam oral solution QL

brivaracetam oral solutionQL 600 mL per 30 days; PA required

brivaracetam oral tabletQL 60 EA per 30 days; PA required

VALTOCO (seizure rescue)QL 10 EA per 30 days; PA indicated for presentations

brivaracetam oral tablet QL

brivaracetam oral tabletQL 60 EA per 30 days; PA required

brivaracetam oral solutionQL 600 mL per 30 days; PA required

Other anticonvulsantsMultiple anticonvulsant QLs and PAs listed in same section

VALTOCO QL

VALTOCO (10 mg dose)QL 10 EA per 30 days; PA required

NAYZILAMQL 10 EA per 30 days; PA required

Other rescue agentsMultiple seizure rescue products carry QLs/PA

donepezil 10 mg QL

donepezil 10 mgQL 60 EA per 30 days

memantine (oral tablet)QL 60 EA per 30 days

memantine oral solutionQL 300 mL per 30 days

AUVELITY QL

OZEMPIC (1 mg dose)QL 3 mL per 28 days; PA required

OZEMPIC (2 mg dose)QL 3 mL per 28 days; PA required

UnitmL used for pen-injector QLs

EXXUA QL

EXXUAQL 30 EA per 30 days; PA required

EXXUA titration packQL 32 EA per 30 days; PA required

AUVELITYQL 60 EA per 30 days; PA required; NE

EXXUA TITRATION PACK QL

EXXUA titration packQL 32 EA per 30 days; PA required

EXXUA (standard)QL 30 EA per 30 days; PA required

Related antidepressantsOther agents listed with ST/QL in same section

aprepitant QL

aprepitantQL 6 EA per 30 days; PA required

dronabinolQL 120 EA per 30 days; B/D noted

granisetron oralB/D noted for some formulations

AIMOVIG QL

AIMOVIGQL 1 mL per 30 days; PA required

EMGALITYQL 2 mL per 30 days (300 mg dose QL 3 mL); PA required

NURTECQL 18 EA per 30 days; PA required

EMGALITY QL

EMGALITY (standard)QL 2 mL per 30 days; PA required

EMGALITY (300 mg dose)QL 3 mL per 30 days; PA required

AIMOVIGQL 1 mL per 30 days; PA required

NURTEC QL

NURTECQL 18 EA per 30 days; PA required

AIMOVIGQL 1 mL per 30 days

EMGALITYQL 2 mL per 30 days

KISQALI FEMARA 200 MG QL

KISQALI FEMARA 200 mgQL 49 EA per 28 days; PA required

KISQALI FEMARA 400 mgQL 70 EA per 28 days; PA required

KISQALI FEMARA 600 mgQL 91 EA per 28 days; PA required

KISQALI FEMARA 400 MG QL

KISQALI FEMARA 400 mgQL 70 EA per 28 days; PA required

KISQALI FEMARA 200 mgQL 49 EA per 28 days; PA required

KISQALI FEMARA 600 mgQL 91 EA per 28 days; PA required

KISQALI FEMARA 600 MG QL

KISQALI FEMARA 600 mgQL 91 EA per 28 days; PA required

KISQALI FEMARA 200 mgQL 49 EA per 28 days; PA required

KISQALI FEMARA 400 mgQL 70 EA per 28 days; PA required

krazati QL

krazatiQL 180 EA per 30 days; PA required

LONSURFPA required (QL not specified in this chunk)

LUMAKRAS (various strengths)PA; QLs vary by strength

LUMAKRAS ORAL TABLET 120 MG QL

LUMAKRAS oral tablet 120 mgQL 240 EA per 30 days; PA required

LUMAKRAS 240 mgQL 120 EA per 30 days; PA required

LUMAKRAS 320 mgQL 90 EA per 30 days; PA required

MEKINIST ORAL SOLUTION RECONSTITUTED QL

MEKINIST oral solution (reconstituted)QL 1170 mL per 28 days; PA required

MEKINIST oral tablet 0.5 mgQL 90 EA per 30 days; PA required

MEKINIST oral tablet 2 mgQL 30 EA per 30 days; PA required

Multiple QL examples varying by product

bexarotene externalQL 60 GM per 30 days; PA required

bexarotene oralPA required; QL varies

ZYKADIAPA required

bexarotene external QL

bexarotene externalQL 60 GM per 30 days; PA required

retinoids (oral)PA required for some presentations

UnitGM used for topical cream/ointment QLs

Various antiviral/antiretroviral examples QL (common 30 EA per 30 days)

INTELENCE; PIFELTRO; TRIUMEQ (examples)Common QL 30 EA per 30 days for many HIV agents

ISENTRESS HDQL 60 EA per 30 days

ISENTRESS oral packetQL 300 EA per 30 days

PREZISTA ORAL SUSPENSION QL

PREZISTA oral suspensionQL 400 mL per 30 days

PREZISTA oral tablet 150 mgQL 240 EA per 30 days

PREZISTA oral tablet 75 mgQL 480 EA per 30 days

VIREAD ORAL POWDER QL

VIREAD oral powderQL 240 GM per 30 days

VIREAD oral tablet (various)QL 30 EA per 30 days for tablets in some strengths

UnitGM used for powder QLs

OZEMPIC QL

OZEMPIC (pen-injector)QL 3 mL per 28 days; PA required

OZEMPIC (2 mg)QL 3 mL per 28 days; PA required

UnitmL used for GLP-1 pen QLs

enoxaparin sodium injection QL examples

enoxaparin sodium injection (30 mg/0.3 mL)QL 18 mL per 30 days

enoxaparin sodium injection (60 mg/0.6 mL)QL 36 mL per 30 days

enoxaparin 100 mg/mL exampleQL 60 mL per 30 days

ELIQUIS DVT/PE starter pack QL

ELIQUIS DVT/PE starter packQL 74 EA per 30 days

ELIQUIS standard packsQL examples include 222 EA or 592 EA per 30 days depending on pack

UnitEA used for pack/tablet QLs

XARELTO ORAL SUSPENSION RECONSTITUTED QL

XARELTO oral suspension (reconstituted)QL 620 mL per 30 days

XARELTO oral tablets 10/20 mgQL 30/60 EA per 30 days depending on strength

XARELTO starter packQL 51 EA per 30 days

fondaparinux sodium QL examples

fondaparinux 10 mg/0.8 mLQL 24 mL per 30 days

fondaparinux 2.5 mg/0.5 mLQL 15 mL per 30 days

fondaparinux (5 mg/0.4 mL)QL 12 mL per 30 days

Multiple QL entries summarized

ENTRESTO (sprinkle)QL 240 EA per 30 days

statin strengths (atorvastatin/rosuvastatin)QL examples: 240/120/60/30 EA per 30 days depending on strength

REPATHAQL varies by presentation (2 mL/28d or 3.5 mL/30d); PA required

REDEMPLO/TRYNGOLZA/REPATHA/EVRYSDI/AUSTEDO/RADICAVA ORS QL examples

REDEMPLOQL 0.5 mL per 84 days; PA required

REPATHAQL 2 mL per 28 days or 3.5 mL per 30 days depending on presentation; PA required

RADICAVA ORSQL 70 mL per 28 days; PA required

methylphenidate HCl ER QL examples

methylphenidate HCl ER (selected)QL 30 / 60 / 90 EA per 30 days depending on formulation/strength

methylphenidate oral solutionQL up to 3000 mL per 30 days for some solutions

Common QL tiersEA per 30 days common for oral tablets; ML for solutions

AUSTEDO QL and PA

OTEZLA oral tablet 20 mgQL 60 EA per 30 days; PA required

OTEZLA therapy packQL 55 EA per 28 days; PA required

OTEZLA XRQL 30 EA per 30 days; PA required

pregabalin QL examples

pregabalin capsules (100–300 mg)QL 60–90 EA per 30 days depending on strength

pregabalin oral solutionQL 900 mL per 30 days

TierListed as Tier 3 for many formulations

MS agents QL/PA examples

AVONEX (pen/syringe)QL 4 EA per 28 days; PA required

BETASERONQL 15 EA per 30 days; PA required

Multiple MS agentsPA required; QLs vary (1–15 EA per 28/30 days or ML limits)

tolvaptan QL

tolvaptan (hyponatremia)QL 120 EA per 30 days; PA required

tolvaptan oral tablet therapy packQL 56 EA per 28 days; PA required

IndicationListed for hyponatremia

topical corticosteroids and dermatologics QL examples

clobetasol propionate external lotion/ointmentQL examples include 118 mL or 60 GM per 30 days depending on formulation

fluocinonide external solutionQL 60 mL per 30 days

fluorouracil external cream 5%QL 40 GM per 30 days

tolvaptan oral tablet QL (numeric) and related entries

tolvaptan oral tabletQL 120 EA per 30 days; PA required

FASENRA prefilled syringe 10 mg/0.5 mLQL 0.5 mL per 30 days; PA required

LOKELMA oral packet 10 GMQL 90 EA per 30 days

FASENRA prefilled syringe QL

FASENRA prefilled syringe 10 mg/0.5 mLQL 0.5 mL per 30 days; PA required

LOKELMA oral packet 10 GMQL 90 EA per 30 days

RELISTOR oralQL 90 EA per 30 days; PA required

DUPIXENT QL examples

DUPIXENT (various presentations)QL 3.42 mL or 8 mL per 30 days depending on presentation; PA required

DUPIXENT 100 mg/0.67 mL syringeQL 1.34 mL per 30 days; PA required

DUPIXENT 200 mg/1.14 mLQL 3.42 mL per 30 days; PA required

SKYRIZI QL examples

SKYRIZI pen/cartridgeQL 1 mL per 28 days or 1.2 mL per 56 days or 2.4 mL per 56 days depending on presentation; PA required

SKYRIZI cartridge 180 mg/1.2 mLQL 1.2 mL per 56 days

SKYRIZI cartridge 360 mg/2.4 mLQL 2.4 mL per 56 days

Adalimumab-adaz presentations QL

adalimumab-adaz 10 mg/0.1 mLQL 0.2 mL per 28 days; PA required

adalimumab-adaz 20 mg/0.2 mLQL 0.4 mL per 28 days; PA required

adalimumab-adaz 40 mg/0.4 mLQL 2.4 mL per 28 days; PA required

adalimumab-adaz 10 mg/0.1ml QL

adalimumab-adaz 10 mg/0.1 mLQL 0.2 mL per 28 days; PA required

adalimumab-adaz 20 mg/0.2 mLQL 0.4 mL per 28 days; PA required

adalimumab-adaz 40 mg/0.4 mLQL 2.4 mL per 28 days; PA required

adalimumab-adaz 20 mg/0.2ml QL

adalimumab-adaz 20 mg/0.2 mLQL 0.4 mL per 28 days; PA required

adalimumab-adaz 10 mg/0.1 mLQL 0.2 mL per 28 days; PA required

adalimumab-adaz 40 mg/0.4 mLQL 2.4 mL per 28 days; PA required

adalimumab-adaz 40 mg/0.4ml QL

adalimumab-adaz 40 mg/0.4 mLQL 2.4 mL per 28 days; PA required

adalimumab-adaz 20 mg/0.2 mLQL 0.4 mL per 28 days; PA required

adalimumab-adaz 10 mg/0.1 mLQL 0.2 mL per 28 days; PA required

ENBREL SUBCUTANEOUS SOLUTION QL

ENBREL subcutaneous solution 25 mg/0.5 mLQL 8 mL per 28 days (examples include various ENBREL presentations); PA required

ENBREL prefilled syringe 25 mg/0.5 mLQL 4 mL per 28 days for some presentations; PA required

ENBREL miniQL 8 mL per 28 days; PA required

OTEZLA QL

OTEZLA oral tablet 20 mgQL 60 EA per 30 days; PA required

OTEZLA therapy packQL 55 EA per 28 days; PA required

OTEZLA XRQL 30 EA per 30 days; PA required

EVENITY QL

EVENITYQL 2.34 mL per 30 days; PA required

BILDYOSQL 1 mL per 180 days

JUBBONTIQL 1 mL per 180 days

Ophthalmic, nasal, injectables and specialty QL examples

gentamicin ophthalmic solutionQL 30 mL per 30 days

tobramycin ophthalmicQL 30 mL per 30 days

dexamethasone ophthalmicQL 30 mL per 30 days

Key Terms & Abbreviations

biosimilar definition entry

biosimilarBiosimilar / interchangeable biosimilar (may be substituted per state law; pharmacy substitution possible)

original biological productReference biologic can be changed/removed if interchangeable biosimilar added

Substitution noteState law governs substitution without new prescription

B/D definition (Part B vs Part D)

B/DPart B vs. Part D — may require review of use and setting to determine Part B (medical) vs Part D (drug) coverage

ImplicationDocumentation describing use/setting may be required to make determination

ContactProviders may need to submit clinical information to support B/D determination

B/D expanded definition

B/D (expanded)Part B vs. Part D — determines whether drug is covered under medical benefit (Part B) or prescription drug benefit (Part D); supporting info may be required

ExamplesSome IV/infusion products flagged B/D in formulary entries

Provider actionSubmit site-of-care/clinical use details when requested

ED abbreviation definition

EDExcluded Drug — not normally covered in a Medicare Prescription Drug Plan; costs for ED do not count toward total drug costs; limited coverage only on Thrive/Thrive Plus plans

Coverage impactAmounts paid for EDs do not help qualify for catastrophic coverage or extra help

Plan exceptionsOnly specific plan variants may cover EDs

PA abbreviation definition

PAPrior Authorization — prescriber must obtain approval from Priority Health Medicare before filling certain drugs; failure to obtain PA may result in non-coverage

When requiredPA is noted next to specific agents in the formulary Requirements/Limits column

Provider actionSubmit clinical documentation per plan process to request PA

HI abbreviation definition

HIHome Infusion — drug may be covered under the medical benefit for home infusion; contact Customer Care for details

ExamplesSeveral IV/injection formulations and some antibiotics/antifungals flagged HI

DocumentationSite-of-care documentation may be required to support HI claims

Abbreviation key — summary of Tiers and flags

Abbreviation key (summary)T1-T5 indicate tiers; PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; HI = Home Infusion; NE = No Express Scripts; LA = Limited Availability

UnitsEA = Each; ML = Milliliters; GM = Grams

Tier 5 noteTier 5 (Specialty) drugs are limited to 30-day supply only

Formulary abbreviations list

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

LocationAbbreviations and legend available beginning on page 9 of formulary

Provider actionFollow plan PA/QL/ST processes as indicated

QL definition (units)

QL (definition)Quantity Limits — maximum units allowed per specified time period (units shown as EA, ML, GM)

Common periodsPer 28 days, per 30 days, per 56 days, per 84 days, per 365 days

ExamplesQL examples appear alongside drugs in Requirements/Limits (e.g., EA per 30 days; ML per 30 days)

PA short definition

PA (short)Prior Authorization — approval required from Priority Health Medicare before filling certain drugs

ConsequenceFailure to obtain PA may result in the plan not covering the drug

Where shownPA flag shown in Requirements/Limits column of formulary entries

Tiers explanation

Tiers summaryT1 Preferred generic; T2 Generic; T3 Preferred brand; T4 Non-preferred; T5 Specialty (Tier 5 limited to 30-day supply)

ImplicationTier affects cost-sharing and supply duration (e.g., Tier 5 = 30-day supply)

Where definedTier legend available in formulary legend beginning page 9

Tier 5 limited to 30-day (Tier legend summary)

Tier 5 supply ruleTier 5 (Specialty) drugs are limited to a 30-day supply only

Where statedNote appears multiple times in formulary legend and sections

ImpactApplies to specialty-tier medications listed in the formulary

Abbreviations and legend (PA, QL, LA, EA, B/D, ST)

Requirement abbreviationsB/D = Part B vs Part D; PA = Prior Authorization; QL = Quantity Limits; NE = No Express Scripts; LA = Limited Availability; ST = Step Therapy; ED = Excluded Drug

UseDisplayed in Requirements/Limits column for each drug

Provider actionRefer to legend for interpretation and follow plan processes

OpenPayer

Priority Health Medicare Formulary (Drug List)

Formulary Coverage & Access

Formulary Codes, Abbreviations & Drug Listings

Prescriber & Provider Requirements

Specified Quantity Limits (Selected Entries)

Home Infusion, Part B vs Part D & Billing Implications

Policy Background & Scope

Key Terms & Abbreviations

Biologic and Biosimilar Handling