Prior AuthorizationRequired 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