Priority Health Medicare MPSERS Formulary (Drug List) — Coverage Criteria
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This document governs the covered prescription drugs, coverage rules (prior authorization, quantity limits, step therapy), and member processes for Priority Health Medicare MPSERS plan members and their prescribers.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules
General formulary coverage
Covered when ALL of the following are met
See Evidence of Coverage for filling details and temporary transition supply rules (30-day transition supply for non-formulary/restricted drugs).
Per-drug coverage with utilization management
Coverage and utilization management indicated per drug entry when ALL of the following fields are present
The drug is covered according to its tier and is subject to the listed utilization management controls.
General coverage rules
Coverage is determined by drug tier and any associated utilization management controls specified per drug/formulation.
Examples in the formulary show anticonvulsants, antidementia agents, and antidepressants with PA/QL/ST flags; follow the per-drug Requirements/Limits for operational coverage.
Formulary administrative criteria
Coverage is indicated per formulary tier with administrative conditions
Tier 5 specialty drugs are limited to a 30-day supply as an administrative rule.
Formulary coverage constraints
Coverage and restrictions for listed drugs:
Many oncology and specialty agents (examples: PEMAZYRE, PIQRAY, ROZLYTREK, REVUFORJ, VITRAKVI, VERZENIO) are marked PA in the formulary.
Quantity limits are enforced per product and presentation.
Document notes this supply limitation for Tier 5 items.
Examples in the formulary include agents with LA noted alongside PA/QL.
General coverage conditional on PA/QL listed
Coverage and requirements as listed per formulary entry
Specific clinical PA criteria or exception processes are referenced elsewhere; providers must follow the plan's PA and QL processes.
Coverage rules (tier assignment with PA/QL)
Coverage posture is tier-based with additional restrictions as noted.
Providers must obtain PA where indicated and ensure dispensed quantities do not exceed the listed QL for each product.
Formulary management criteria
Coverage/management rules indicated by flags (PA, QL, ED, ST, LA, HI) applied to listed products.
Home infusion (HI) or B/D designations affect site-of-care and billing; see per-drug rows for those flags.
Standard formulary coverage with utilization management
Coverage is provided per formulary tier with utilization management; drugs listed are covered according to tier but may require PA or have QL limits.
Specific PA submission requirements and clinical criteria are located in the plan's prior authorization guidelines and on referenced formulary pages.
Entries labeled ED (Excluded Drug) are drugs that the Medicare Prescription Drug Plan does not normally cover. When a drug is designated ED, the member’s cost-sharing for that drug does not count toward their total drug costs and therefore does not help the member qualify for catastrophic coverage or receive additional 'extra help' subsidies.
Excluded drugs (ED) do not count toward catastrophic coverage; amounts a member pays for an ED drug are excluded from the total drug cost calculation used to determine qualification for catastrophic benefits.
Within this extract the legend defines ED (Excluded Drug), but the pages shown do not attach the ED flag to many specific formulary rows in these chunks. The document notes abbreviations and that full abbreviation definitions begin on page 10.
Specialty products assigned to Tier 5 are administratively limited to a 30-day supply. The formulary legend and multiple drug entries reiterate the Tier 5 = 30-day supply only policy; some Tier 5 rows also carry flags such as ED or NE elsewhere in the full formulary.
Although many product rows appear in the extract, there is no single contiguous list of explicitly excluded drugs in these chunks. Some individual items elsewhere in the document are marked ED, but the displayed excerpts do not present a complete excluded-drug list.
The abbreviation ED (Excluded Drug) is present in the formulary legend and used in several rows in the full document, but the specific excluded products are not comprehensively listed within this excerpt.
An administrative supply limitation applies to specialty drugs: Tier 5 drugs are limited to a 30-day supply only. This is an operational rule noted in the legend and applied to Tier 5 entries.
This extract does not include explicit 'not medically necessary' (NMN) determinations for drugs. Instead, coverage limitations in the excerpt appear as administrative flags (for example, PA, QL, ED, and ST) applied to specific formulary entries.
Several products in the listings shown are explicitly marked ED in the document (examples in other pages include topical and vitamin preparations). The extract includes sample rows where ED is applied to specific products.
Entries marked ED are excluded from coverage under the Medicare Prescription Drug Plan. The formulary uses ED to denote products that will generally not be covered and may be denied at claim processing.
The presence of the ED flag next to a product indicates the plan considers that product excluded and not payable under the Part D formulary. Examples of product lines elsewhere in the document show ED applied to certain topical agents and nutritional/vitamin products.
For the drugs displayed in the provided excerpt, no comprehensive excluded-drug list is presented. The extract includes the ED definition and some rows with ED, but many shown entries do not carry explicit exclusion markings within these chunks.
No explicit statements declaring drugs as 'not medically necessary' appear in these chunks. Coverage constraints are expressed through administrative flags and the formulary’s Requirements/Limits columns rather than NMN language in this excerpt.
Coverage and utilization restrictions in the extract are implemented via requirement/limit flags — PA (Prior Authorization), QL (Quantity Limits), ST (Step Therapy), ED (Excluded Drug) and other abbreviations — rather than explicit 'not medically necessary' rulings in the text shown.
Drug List and Coding Indicators
| diclofenac sodium er | Listed as diclofenac sodium er (Non-preferred, Tier 4) |
| diclofenac potassium 50 mg tablet | Listed as diclofenac potassium oral tablet 50 mg (Tier 2) |
| diclofenac sodium external solution 1.5% | Topical diclofenac sodium external solution 1.5% (Tier 4) - QL 750 ML per 30 days |
| diclofenac delayed release 50 mg, 75 mg | diclofenac sodium oral tablet delayed release 50 mg, 75 mg (Tier 2) |
| diclofenac-misoprostol dr | diclofenac-misoprostol oral tablet delayed release (Tier 4) |
| celecoxib oral | celecoxib oral (Tier 2) |
| ibuprofen oral tablet 400 mg, 600 mg, 800 mg | IBU oral tablet 400 mg, 600 mg, 800 mg (Generic Tier 2) |
| ibuprofen oral suspension 100 mg/5ml | ibuprofen oral suspension 100 mg/5 mL (Tier 4) |
| celecoxib oral | celecoxib — Tier 2 |
| diclofenac potassium 50 mg tablet | diclofenac potassium 50 mg — Tier 2 |
| diclofenac sodium er | diclofenac sodium er — Tier 4 |
| diclofenac sodium external solution 1.5% | Topical diclofenac 1.5% — Tier 4; QL 750 ML per 30 days |
| ibuprofen oral tablet 400 mg, 600 mg, 800 mg | ibuprofen oral tablets 400/600/800 mg — Tier 2 |
| ibuprofen oral suspension 100 mg/5ml | ibuprofen suspension 100 mg/5 mL — Tier 4 |
| mefenamic acid oral | mefenamic acid — Tier 4; QL 30 EA per 30 days |
| meloxicam oral tablet | meloxicam — Tier 1 |
| mefenamic acid | QL (30 EA per 30 days) |
| linezolid oral tablet | QL (56 EA per 28 days) |
| No codes listed |
| PA | Prior Authorization |
| QL | Quantity Limits |
| ST | Step Therapy |
| LA | Limited Availability |
| B/D | Part B vs. Part D |
| EA | Each |
| ED | Excluded Drug |
| HI | Home Infusion |
| NE | No Express Scripts |
| ML | Milliliters |
| RYBELSUS | RYBELSUS — PA; QL (30 EA per 30 days) |
| FIASP PENFILL | FIASP PENFILL — listed |
| HUMALOG | HUMALOG products — listed |
| benazepril hcl 20 mg | benazepril 20 mg — QL (120 EA per 30 days) |
| ramipril | ramipril — various QLs listed |
| atorvastatin 10 mg | atorvastatin 10 mg — QL (240 EA per 30 days) |
| rosuvastatin 10 mg | rosuvastatin — QL (120 EA per 30 days) |
| fluorouracil external cream 5% | fluorouracil external cream 5% — QL (40 GM per 30 days) |
| LOKELMA ORAL PACKET 5 GM | LOKELMA — QL (30 EA per 30 days) |
| tolvaptan oral tablet therapy pack | tolvaptan — PA; QL (56 EA per 28 days) |
| AMVUTTRA | AMVUTTRA — PA; QL (0.5 ML per 90 days) |
| fluorouracil external cream 5% | QL (40 GM per 30 days) |
| tacrolimus ointment | tacrolimus — QL (varies) |
| omeprazole oral capsule delayed release 20 mg | Tier 1 — omeprazole 20 mg — listed |
| pantoprazole sodium oral tablet delayed release | pantoprazole — Tier 1 |
| diclofenac sodium ophthalmic | diclofenac sodium ophthalmic — Tier 2 |
| ketorolac tromethamine ophthalmic solution 0.5% | ketorolac ophthalmic 0.5% — QL (20 ML per 30 days) |
| restasis multidose ophthalmic emulsion 0.05% | Restasis — QL (5.5 ML per 30 days) |
Required Provider Steps and Denial Risks
Required Provider Steps and Denial Risks
Priority Health requires prior authorization (PA) for many listed drugs and drug categories. Prescribers or members must obtain PA before dispensing PA‑marked medications; claims submitted without an approved PA may be denied or not paid. PA triggers include many specialty, high‑cost, oncology, orphan, and select non‑specialty agents (examples in the formulary: XIFAXAN, DIFICID, XCOPRI, AUVELITY, EXXUA, ZURZUVAE, OTEZLA, many oncology oral agents such as VENCLEXTA/VERZENIO/ROZLYTREK, specialty biologics and injectables like DUPIXENT, COSENTYX, HUMIRA, and orphan/specialty agents including AMVUTTRA, ENDARI, NULIBRY, REPATHA, NEXLETOL, EVRYSDI, and others). Quantity limits (QL) are enforced per formulary entries (e.g., 30 EA per 30 days, ML/GM/EA per period); exceeding the listed QL can trigger denial, partial payment, or a requirement to provide additional justification. Some products are Limited Availability (LA), Home Infusion (HI), or excluded (ED/NE) and have special handling or may be denied. Step therapy (ST) requirements apply for selected agents (examples: DIFICID, FETZIMA, TRINTELLIX, febuxostat, paliperidone ER formulations, select ophthalmics) — formulary rows mark ST where it applies; specific program rules are in the full formulary definitions.
- PA required for selected drugs (formulary rows marked PA)
- PA required for listed drugs including many Tier 5/specialty agents and select Tier 3–4 branded drugs
- Prior authorization required before filling PA‑marked prescriptions; lack of PA may lead to denial
- Prior Authorization required for specialty, oncology, orphan, and high‑cost drugs (examples listed in formulary)
- PA required for listed PA items such as injectables, pen needles, specialty pens and supplies
- PA required for specified drugs (examples: XIFAXAN strengths, DIFICID, XCOPRI, AUVELITY, EXXUA, ZURZUVAE)
- Selected drugs requiring prior authorization: OTEZLA, RELISTOR, many immunologics/biologics, and numerous oncology oral agents
- Specialty/orphan drugs require PA (examples: AMVUTTRA, ENDARI, NULIBRY, PROLASTIN‑C, REVCOVI, VYNDAMAX)
- Prior Authorization requirement — claims for PA‑labeled drugs without approval risk denial
- Prior authorization denial risk: failure to obtain PA may result in non‑coverage or denial of the claim
- Prior authorization triggers include: specialty tier (T5) designation, certain strengths/forms, LA/HI designations, and formulary PA flags
- Selected PA triggers called out: XIFAXAN 200mg/550mg, LIDOCANE patches, ESLICARBAZEPINE strengths, RUFNAMIDE, XCOPRI packs, DIHYDROERGOTAMINE nasal
- Specialty/oncology PA triggers: many oral oncology agents (VENCLEXTA, VERZENIO, ROZLYTREK, PIQRAY, etc.) list PA and QL
- Prior Authorization indicated on formulary legend (PA abbreviation and explanation provided)
- Quantity limit exceeding: exceeding QL (EA/ML/GM per time period) may trigger denial or require justification
- Exclusion/denial triggers: ED (Excluded Drug) and NE entries indicate non‑covered or limited supply channels; market withdrawals may be immediately removed
- Prescriber supporting statement required when requesting an exception — prescriber must explain medical reasons; standard decision timeline: 72 hours (or 24 hours for expedited requests)
- Submission of clinical setting/use: B/D (Part B vs Part D) entries require prescriber submission of clinical use/setting to determine coverage
- Documentation for specialty drugs: Tier 5/specialty drugs have PA and QL; providers must submit PA documentation per payer process
- PA and QL documentation: prescribers must supply medical necessity documentation and dosing justification to satisfy PA and QL fields
- Quantity limits documented on formulary: many entries list exact QL (e.g., 30 EA per 30 days, ML per 30 days, GM per 30 days) and must be observed
- Documentation for PA: prescribers should supply required documentation to satisfy PA/QL/ST/LA fields per formulary notes
- PA and QL requirements: PA and quantity limits are enforced for many specialty and select non‑specialty agents
- Quantity limits and LA: Limited Availability products often also have PA and specific QL enforced
- Formulary abbreviations and documentation guidance: legend explains B/D, PA, QL, ST, LA, NE, ED and tier definitions; consult full formulary definitions beginning on page 10
- Reference for abbreviations and rules: full definitions and program rules are available in the formulary (see page 10) and online; the formulary was last updated 4/21/2026
- Step therapy requirements: ST applies where marked — members may be required to try preferred drugs first before coverage of alternatives
- Step therapy flags (no specific rules in excerpt): ST is indicated in rows but specific step rules are in the full formulary
- Step therapy for select agents: examples include DIFICID, FETZIMA, TRINTELLIX, febuxostat, paliperidone ER
- Step therapy referenced: ST referenced in legend and entries; consult full formulary for program details
- Step therapy notation: products with ST are marked in Requirements/Limits
- Step therapy noted: select ophthalmics (difluprednate, loteprednol) and others are marked ST
- Step therapy (legend): ST abbreviation explained in the List of Abbreviations and legend
- Step therapy (general note): ST abbreviation present; details and exceptions must be referenced in the full program documentation
- Step therapy for select ophthalmics: difluprednate and loteprednol formulations are marked ST
Initial Therapy and Entry Requirements
Initial therapy controls
Initial therapy controls
Examples: DIFICID and selected antidepressants (e.g., FETZIMA, TRINTELLIX) show ST or ST-related flags on formulary rows; where ST is listed, prior steps and documentation must be met per plan process.
| Coverage rule | Details |
|---|---|
| Step therapy required | |
| Some drugs require step therapy; members must try specified first-line drugs before the plan will cover alternative drugs for the same condition. Check the Requirements/Limits column in the formulary to determine whether ST applies to a specific product. |
| Step guidance | Notes |
|---|---|
| Try preferred drug(s) first | |
| ST (Step Therapy) may require members to trial preferred agents before coverage of non-preferred alternatives; if the preferred agent is ineffective or not tolerated, the plan will cover the alternative per formulary procedures. |
| Product | Step therapy status |
|---|---|
| DIFICID oral suspension (reconstituted) | |
| Requirements/Limits = ST; QL (136 ML per 10 days) | |
| DIFICID oral tablet | |
| Requirements/Limits = ST; QL (20 EA per 10 days) |
| Products | Step therapy status |
|---|---|
| FETZIMA | |
| Requirements/Limits = ST; QL (30 EA per 30 days); NE (not available at Express Scripts) per formulary row | |
| TRINTELLIX | |
| Requirements/Limits = ST; QL (30 EA per 30 days); NE per formulary row | |
| vilazodone | |
| Listed with ST in formulary rows (step therapy indicated) | |
| febuxostat | |
| Listed with ST in formulary rows (step therapy indicated) |
| Legend flag | Implication |
|---|---|
| ST (Step Therapy) flag in formulary legend | |
| The formulary legend includes ST as an abbreviation meaning Step Therapy, but specific step-therapy sequences or product-level rules are not detailed in this extract; check full formulary for sequences. |
| Product group | Step therapy rule |
|---|---|
| Paliperidone ER formulations | |
| Requirements/Limits = ST; QL specified (e.g., 1.5/3/9 mg ST; 30 EA per 30 days; 6 mg ST with QL 60 EA per 30 days) indicating step therapy applies to select extended-release paliperidone products. |
| Reference | Detail |
|---|---|
| Abbreviations list includes ST | |
| Step Therapy (ST) is identified among the requirements/limits abbreviations, but the extract does not provide the specific step sequences for most products. |
| ST indicator | Detail |
|---|---|
| ST indicates Step Therapy may apply | |
| Formulary rows show ST as a possible requirement flag; this extract does not provide required step sequences or order of therapies where ST is indicated. |
| Product | ST note |
|---|---|
| Calcitriol external | |
| Requirements/Limits = ST (step therapy) listed in formulary row; specific step requirements not provided in this excerpt. |
| Product | Coverage implication |
|---|---|
| Calcitriol external | |
| Listed with Requirements/Limits = ST; where ST is indicated on the formulary, prior steps must be documented per plan rules (specific steps not shown in this extract). |
| Legend reference | Note |
|---|---|
| ST referenced in legend | |
| Step Therapy (ST) is included in the formulary legend/abbreviations, but product-level ST rules are not included in the provided extract. |
| Abbreviation | Presence |
|---|---|
| ST | |
| Step therapy is defined as an abbreviation (ST) in the formulary legend; the extract does not include the detailed step therapy criteria or required prior agents. |
| Ophthalmic product | Step therapy status |
|---|---|
| difluprednate (ophthalmic) | |
| Requirements/Limits = ST (step therapy) as shown in formulary rows for ophthalmic anti-inflammatories. | |
| loteprednol formulations (ophthalmic gel/suspension) | |
| Requirements/Limits = ST (step therapy) listed for multiple loteprednol presentations in the formulary. |
Quantity Limits by Product
Site-of-Care and Benefit Determination
Formulary Abbreviations and Tier Definitions
Policy Background and Scope
This formulary lists covered prescription drugs and biologics (including biosimilars) for the Priority Health Medicare MPSERS plan. Drugs are grouped by therapeutic class and each entry shows tier assignment and any applicable administrative controls (for example, PA, QL, ST, ED, or HI). Coverage follows tier-based rules and the Requirements/Limits shown next to each drug.
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