Provide clinical info for PA and B/D determinations

Prescriber must provide clinical details when a drug is designated B/D (Part B vs Part D) or when a PA is required; physician-submitted information may be needed to determine benefit responsibility and to obtain prior authorization.

• If B/D is shown, the physician must describe the drug's intended use and setting to determine Part B vs Part D coverage.
• Prior authorization must be obtained for drugs marked PA before the plan will cover them.

Obtain PA for listed PA-marked formulations

Request prior authorization for any drug entry labeled 'PA' (examples in the formulary include lidocaine patch 5% and LIDOCAN products); submit the PA per Priority Health Medicare procedures before dispensing.

• Lidocaine external patch 5% — Requirements/Limits = PA; QL (90 EA per 30 days).
• LIDOCAN and LIDOCAN III entries are listed with Requirements/Limits = PA; QL (90 EA per 30 days).

PA required for specialty/non-preferred drugs

Obtain prior authorization for specialty and non-preferred high-tier drugs marked PA (e.g., AUVELITY, EXXUA, ZURZUVAE); claims require PA approval before payment.

• AUVELITY — Requirements/Limits = PA; QL (60 EA per 30 days).
• EXXUA — Requirements/Limits = PA; QL (30 EA per 30 days); ZURZUVAE — Requirements/Limits = PA.

PA required for many oncology oral agents

Many oral oncology agents are subject to prior authorization and associated quantity limits; prescribers must request PA prior to dispensing for coverage to be approved.

• Examples: PEMAZYRE, PIQRAY, QINLOCK and numerous other Tier 5 oncology oral agents list Requirements/Limits = PA and specific QL values.
• Some oncology products also display Limited Availability (LA) and must follow special handling.

Get PA and follow QL for Tier 5 specialty drugs

Prior authorization is required for numerous Tier 5 specialty drugs; also confirm and adhere to listed quantity limits (QL) when submitting PA requests.

• Examples: PEMAZYRE — PA; QL (14 EA per 21 days). PIQRAY — PA; QL varies by strength. QINLOCK — PA; QL (90 EA per 30 days).

Secure PA for insulin supplies, pen needles, and specified oral agents

Drugs with 'Requirements/Limits = PA' listed (including certain insulin supplies, pen needles, and oral agents such as RYBELSUS) require prior authorization before coverage.

• RYBELSUS — Requirements/Limits = PA; QL (30 EA per 30 days).
• Embecta pen needles and other insulin supplies are listed with Requirements/Limits = PA.

PA required for selected specialty/high-cost meds

Obtain prior authorization for selected specialty or high-cost medications identified in the formulary (examples include REDEMPLO, REPATHA presentations, NEXLETOL and NEXLIZET).

• REPATHA (various presentations) — Requirements/Limits = PA; QL (2 ML per 28 days; Pushtronex 3.5 ML per 30 days).
• NEXLETOL and NEXLIZET — Requirements/Limits = PA; QL (30 EA per 30 days).

Submit PA for all PA‑marked drugs

Any drug entry explicitly labeled 'PA' in the formulary requires prior authorization before coverage; prescribers must submit PA to avoid non-coverage.

• Examples include NEXLETOL, NEXLIZET, REPATHA formulations and many specialty agents marked with PA.
• PA must be approved prior to dispensing for coverage to be provided.

PA required for select dermatology and specialty agents

Obtain prior authorization for listed products such as OTEZLA (PA; QL 60 EA/30 days) and PANRETIN (PA; QL 60 GM/30 days) as indicated in the formulary.

• OTEZLA ORAL TABLET 30 MG — Requirements/Limits = PA; QL (60 EA per 30 days).
• PANRETIN — Requirements/Limits = PA; QL (60 GM per 30 days).

PA required for certain high-cost hormonal and metabolic products

Request prior authorization for high-cost or specialized therapies noted in the formulary (examples include VYNDAMAX, INCRELEX, ACTHAR) per the Requirements/Limits column.

• VYNDAMAX — Requirements/Limits = PA; QL (30 EA per 30 days).
• INCRELEX — Requirements/Limits = PA; LA. ACTHAR — Requirements/Limits = PA (listed among hormonal agents).

PA required for specialty biologics (e.g., COSENTYX, DUPIXENT, SKYRIZI)

Many specialty biologics and immunomodulators require prior authorization; verify PA and quantity limits for agents such as COSENTYX, DUPIXENT, SKYRIZI and similar biologics before prescribing.

• COSENTYX (300 mg) — Requirements/Limits = PA; QL (8 ML per 28 days).
• DUPIXENT and SKYRIZI presentations — Requirements/Limits = PA; QL specified per formulation.

PA required for pulmonary and cystic fibrosis specialty agents

Prior authorization is required for select pulmonary and cystic fibrosis specialty agents; follow PA procedures and note any B/D or LA designations affecting benefit/payment.

• CAYSTON — Requirements/Limits = PA; LA. KALYDECO — Requirements/Limits = PA; QL (56 EA per 28 days). TRIKAFTA — Requirements/Limits = PA; QL (84 EA per 28 days).
• PULMOZYME — Requirements/Limits = B/D (Part B vs Part D) for inhalation solution).

Meet step therapy prior to coverage

Prescribers may be required to try specified first‑line (preferred) drugs before the plan will cover alternative agents; step therapy must be satisfied per the formulary where ST is indicated.

• If ST is listed, the member must trial the required agent(s) and fail or be intolerant before the alternate is covered.
• Step therapy rules are available in the formulary and online step therapy documents.

Document prior trials when ST applies

When 'ST' (Step Therapy) appears in the formulary, members must generally trial preferred agents first; prescribers should document prior trials when requesting coverage of non‑preferred drugs.

• Examples of ST applications include some antidepressants and other therapeutic classes listed with ST.
• Provide documentation of prior trial and failure/intolerance when submitting an exception or PA.

Step therapy applies to select antidepressants (FETZIMA, TRINTELLIX, vilazodone)

Certain agents are expressly subject to step therapy in the formulary (examples: FETZIMA, TRINTELLIX, vilazodone); prescribers must follow ST requirements and document trials of preferred agents.

• FETZIMA — Requirements/Limits = ST; QL (30 EA per 30 days). TRINTELLIX — Requirements/Limits = ST; QL (30 EA per 30 days).
• Vilazodone — Requirements/Limits = ST; QL (30 EA per 30 days).

Recognize 'ST' in the formulary key

The formulary legend uses the abbreviation 'ST' to denote Step Therapy; treat this as the recognized step therapy indicator when reviewing formulary entries.

• 'ST' is defined in the abbreviations/key and indicates a step therapy requirement where applied to a product entry.

Paliperidone ER requires ST and QL adherence

Paliperidone ER extended‑release oral tablet entries note Step Therapy (ST) and specific quantity limits; prescribers must follow those ST requirements when requesting coverage.

• Paliperidone ER — Requirements/Limits = ST; QL (30 EA per 30 days for some strengths; 60 EA for others).

Check full formulary for ST details when abbreviation present

The formulary includes 'ST' references in the abbreviations, but some excerpts do not list specific step‑therapy rules; consult the full formulary or step therapy documents for details.

• Where ST is indicated on the full glossary, specific step rules may apply though not shown in every excerpt.

ST referenced in abbreviations — verify specifics elsewhere

The formulary legend and some product lines reference Step Therapy (ST) but not all excerpts include the full ST steps; verify the full formulary or policy documents for step details.

• ST is referenced in the abbreviations but specific step requirements may not be present in every extract.

Comply with ST when applied (e.g., calcitriol external)

Where 'ST' is noted for a product (e.g., calcitriol external), prescribers must comply with the step therapy requirement prior to coverage of non‑preferred alternatives.

• Calcitriol external — Requirements/Limits = ST. Provide documentation of prior trial per ST when requesting coverage.

Review full formulary for ST application when not shown

The formulary legend includes 'ST' but some product listings in this extract show no specific ST rules; prescribers must review the full formulary for step therapy applicability.

• Document indicates 'ST' in the key but this partial extract lacks explicit step therapy steps for many listed drugs.

ST defined in formulary key — follow where indicated

The formulary key defines ST (Step Therapy) as an authorization control; where ST is designated for a product you must follow step requirements or submit documentation for exception.

• ST is defined in the Requirement abbreviations and must be followed where applied to a product entry.

Follow ST or request an exception with documentation

ST is listed in the formulary legend; if a specific product entry includes 'ST', prescribers must meet those step therapy requirements or request an exception with supporting documentation.

• The legend lists ST; specific ST requirements may be found in product entries or the full step therapy policy.

Provide prescriber's supporting medical statement for exceptions

When requesting an exception, the prescriber must provide a supporting medical statement explaining why the member needs the exception; decisions are generally made within 72 hours (24 hours if expedited).

• Include clinical justification from the prescriber describing why alternative formulary options are not suitable.
• Standard decision timeframe = 72 hours; expedited decisions = 24 hours if criteria for urgency are met.

Submit clinical info to determine Part B vs Part D (B/D)

If Part B vs Part D coverage is ambiguous (B/D), the physician should submit information describing the drug's use and setting to determine benefit responsibility.

• B/D designation may require physician-submitted details to determine whether the drug is covered under Medicare Part B or Part D.
• Submit documentation of intended use/setting with the PA or benefit determination request.

Provide documentation to meet PA, QL, and ST requirements

Prescribers must supply documentation to satisfy prior authorization (PA) requirements and to support requests that exceed quantity limits (QL) or override step therapy (ST) when requesting coverage.

• If a drug entry lists 'PA', include relevant clinical notes, diagnoses, prior therapy and rationale.
• Document dose, frequency, and justification when requesting overrides of QL or ST.

Document justification for PA/QL/LA/HI requests

When requesting authorization or overrides, provide clinical information justifying exceeding quantity limits or requesting handling for Limited Availability (LA) or Home Infusion (HI).

• Document why the requested quantity exceeds the QL and include clinical rationale and dosing schedule.
• For LA or HI products, include distribution/setting needs and justification.

Attach documentation when prescribing PA‑listed drugs

Include supporting clinical documentation with prescriptions for any drug entry that lists 'PA'; ensure documentation aligns with the product's stated quantity limits and rationale for use.

• PA entries must be accompanied by clinical justification and any required diagnostic or prior-treatment evidence.
• Confirm QL values in the formulary and include dosing details in the PA submission.

Document dose/frequency for QL drugs (e.g., RYBELSUS)

Document the dose and frequency when prescribing drugs with quantity limits (example: RYBELSUS QL 30 EA per 30 days); provide this information if requesting an override.

• RYBELSUS — QL (30 EA per 30 days); include prescribed dose and intended frequency when seeking coverage or an exception.

Submit clinical support with PA for specialty agents (REPATHA, NEXLETOL, KERENDIA)

Provide supporting clinical records for prior authorization requests for specialty therapies (examples in the formulary: REPATHA, NEXLETOL, NEXLIZET, KERENDIA); include diagnosis, prior treatments, and dosing.

• REPATHA — PA; QL (2 ML per 28 days or Pushtronex 3.5 ML per 30 days).
• NEXLETOL/NEXLIZET — PA required; include lipid management history and rationale.

Follow quantity limits for strengths/formulations

Adhere to specified quantity limits for strengths and formulations; claims exceeding listed QL values may be denied without an approved authorization.

• Rosuvastatin 5/10 mg — QL (120 EA per 30 days); 20 mg — QL (60 EA per 30 days); 40 mg — QL (30 EA per 30 days).
• REPATHA formulations — QL per presentation (2 ML per 28 days; Pushtronex 3.5 ML per 30 days).

Provide required documentation per formulary indicators (PA/QL/ST/LA/HI/ED)

When an authorization type is listed (PA, QL, ST, LA, HI, ED), include the corresponding documentation and follow the formulary key; these indicators reflect required claims/benefit documentation.

• Formulary abbreviations define required controls (PA, QL, ST, LA, HI, ED); include required documentation per the key when submitting requests.
• ED = Excluded Drug (not covered); HI = Home Infusion; B/D = Part B vs Part D — may affect benefit responsibility.

Follow formulary requirement indicators on claims and PA submissions

Formulary entries include indicators (PA, QL, B/D, LA) that must be followed; prescribers should ensure claims reflect these requirements to prevent coverage issues.

• Check the Requirements/Limits column for PA, QL, B/D or LA designations before submitting prescriptions.
• Include relevant clinical and billing details with PA submissions to align with plan rules.

Document per QL and PA examples when submitting claims

Quantity limits and prior authorization are specified for many products (examples: epinephrine auto-injector QL 4 EA/30 days; KALYDECO PA; QL 56 EA/28 days); provide documentation consistent with these limits when requesting coverage.

• Epinephrine auto‑injector — QL (4 EA per 30 days).
• KALYDECO — PA required; QL (56 EA per 28 days).

Risk of non‑coverage if PA not obtained

Failure to obtain required prior authorization may result in Priority Health Medicare denying coverage for the drug; prescribers must secure PA before dispensing PA‑designated drugs.

• If prior authorization is not obtained for PA‑required drugs, Priority Health Medicare may not cover the medication.

PA not obtained may cause denial of coverage

If prior authorization is not secured, Priority Health Medicare may deny payment for the medication; ensure PA is in place to avoid non‑coverage.

• Failure to obtain PA may result in the plan not covering the drug.

PA/QL/ST enforce coverage at claim adjudication

Drugs marked with PA, QL, or ST will trigger authorization or quantity enforcement at claim adjudication; meet those requirements to avoid denial.

• PA or QL indicators on a formulary entry will be enforced during adjudication and may require an approved PA or override.
• ST entries require documentation of prior trials before coverage will be allowed.

PA/QL/LA noncompliance may lead to denial for oncology agents

Coverage for many specialty oncology agents can be denied without prior authorization; quantity limits and limited availability designations also impact coverage decisions.

• Specialty oncology oral agents frequently list PA and QL — obtain PA and adhere to QL to avoid denial.
• LA designations may restrict where a drug is available and require special handling.

Failure to obtain PA or exceed QL may cause denial

Requests for specialty drugs submitted without prior authorization or that exceed quantity limits may be denied per the formulary; secure PA and document clinical need when limits are exceeded.

• Many Tier 5 specialty drugs list PA and QL; claims without approved PA or exceeding QL are subject to denial.
• Examples include PIQRAY, PEMAZYRE, QINLOCK with specific QL values.

PA required for certain listed drugs to avoid denial

Coverage may be denied unless prior authorization is obtained for drugs where the Requirements/Limits column lists 'PA' (examples: RYBELSUS, various insulin supplies and pen needles).

• RYBELSUS — PA required; QL (30 EA per 30 days).
• Multiple insulin supplies and pen needles in the formulary show Requirements/Limits = PA.

PA and QL enforcement may result in denial for certain specialty agents

Requests for certain specialty agents (REPATHA, NEXLETOL, NEXLIZET, KERENDIA, REDEMPLO, TRYNGOLZA) may be denied if prior authorization requirements are not met or quantity limits are exceeded.

• REPATHA — PA required; QL varies by presentation. KERENDIA — PA; QL (30 EA per 30 days).
• Supply and prior authorization conditions must be met for coverage.

PA‑marked medications require approved PA prior to coverage

Medications marked 'PA' must have prior authorization approved before the plan will cover them; submit PA documentation to prevent coverage denial.

• Examples: NEXLETOL, NEXLIZET, REPATHA products and many MS agents are listed with PA.
• PA must be approved for these products prior to dispensing to secure coverage.

ED entries are excluded and may be denied if billed

Drugs designated 'ED' (Excluded Drug) are not covered under the Medicare Prescription Drug Plan and will be denied if billed to the plan.

• ED entries in the formulary indicate exclusion from coverage and do not count toward drug spend or catastrophic coverage.

Tier 5 specialty drugs limited to 30‑day supply — risk of denial if exceeded

Tier 5 specialty drugs are limited to a 30‑day supply; requests exceeding that supply or submitted without required PA/QL may be denied.

• Note: Tier 5 drugs are specialty and are limited to 30‑day supply only per the formulary.
• Obtain PA and adhere to QL to avoid denial for Tier 5 products.

ED‑designated drugs will not be covered

Excluded drugs (ED) listed in the formulary will not be covered and claims for ED products may be denied.

• ED designation removes coverage under the Medicare Prescription Drug Plan; verify coverage before prescribing.

PA required — risk of denial without approved authorization

Drugs marked 'PA' require prior authorization and may be denied without an approved authorization; submit PA before dispensing to ensure coverage.

• Examples include INCRELEX and multiple hormonal/biologic agents with Requirements/Limits = PA; LA.
• PA status must be verified and approved prior to claim submission.

PA/QL commonly required for specialty drugs — obtain PA and follow QL

Specialty drugs in the formulary commonly list PA and/or QL; prescribers must request PA and observe QL values for these products to obtain coverage.

• Many specialty and high-tier drugs (e.g., SOMAVERT, SIGNIFOR, COSENTYX, DUPIXENT) require prior authorization.
• Check QL and PA indicators before prescribing to avoid claim rejection.

PA required for specialty pulmonary and CF agents

Prior authorization is required for many specialty pulmonary and cystic fibrosis agents (examples: CAYSTON, KALYDECO, TRIKAFTA); absence of PA may lead to coverage denial.

• CAYSTON — Requirements/Limits = PA; LA. KALYDECO — Requirements/Limits = PA; QL (56 EA per 28 days). TRIKAFTA — Requirements/Limits = PA; QL (84 EA per 28 days).

Contact CustomerCare for HI (Home Infusion) coverage/billing

Drugs labeled HI (Home Infusion) may be covered under the medical benefit; providers should contact Customer Care for site‑of‑care and billing guidance.

• Example: vancomycin IV presentations list Requirements/Limits = HI.
• Contact CustomerCare at 844.403.0847 for Home Infusion coverage details.

Tier 5 specialty drugs limited to 30‑day supply at pharmacy

Tier and supply rules apply at the pharmacy level — Tier 5 (Specialty) drugs are limited to a 30‑day supply only; ensure prescriptions and claims reflect this supply rule.

• Note: Tier 5 drugs are 30‑day supply only as indicated in the formulary notes.

Verify HI designation and site‑of‑care for injectables/infusions

Some injectable or infusion products have an HI designation and may be covered under the medical benefit; prescribers should verify site‑of‑care and billing requirements before ordering.

• Example: furosemide injection — Requirements/Limits = HI. Verify medical benefit coverage and billing process prior to dispensing.

Monitor formulary updates for biosimilar additions and tier changes

Formulary may add biosimilars or interchangeable biosimilars; when added, the brand/original biologic may move to a different tier or have new restrictions — prescribers should check formulary updates.

• Interchangeable biosimilars may be substituted per state law without a new prescription where allowed.
• Formulary changes are posted monthly and may affect biologic tiering or restrictions.