Prior authorization requirement

Priority Health Medicare requires prior authorization (PA) for certain drugs; providers or prescribers must obtain PA approval from Priority Health Medicare before the prescription is filled or the plan may not cover the drug.

• PA is required where 'PA' is shown in the Requirements/Limits column on the formulary.
• Failure to obtain PA may result in noncoverage of the drug.

Prior Authorization Requirement

Priority Health Medicare requires prior authorization (PA) for drugs annotated 'PA' in the formulary; prescribers must submit a PA request specifying the product, strength, and quantity before dispensing.

• PA must be obtained prior to filling when the formulary entry shows 'PA'.
• Tier 5 specialty drugs commonly require PA and are limited to a 30‑day supply.

PA required for select specialty and listed products

Certain specialty and select products explicitly list 'PA' next to the drug (examples include XIFAXAN 200 mg/550 mg, DIFICID, many anticonvulsants); prescribers must obtain PA as indicated on each drug line.

• XIFAXAN 200 mg — PA; QL (9 EA/30 days); XIFAXAN 550 mg — PA; QL (60 EA/30 days).
• DIFICID oral suspension/tablet — ST; QL (136 mL/10 days or 20 EA/10 days).
• Multiple anticonvulsants (e.g., brivaracetam) list PA and QL.

Prior authorization required for listed specialty and select agents

Many specialty and select agents listed across the formulary require prior authorization (PA); providers must check each formulary entry and obtain PA for those products before coverage is approved.

• Examples include eslicarbazepine acetate (PA; QL), rufinamide (PA), AUVELITY (PA; QL; NE).
• Oncology and specialty oral agents frequently show PA in Requirements/Limits.

Prior Authorization Requirement for oncology oral agents

Prior authorization is required for many oral oncology and molecular-targeted agents shown as Tier 5 with 'PA' in the Requirements/Limits column; obtain PA before prescribing these oral oncology drugs to avoid denial.

• Examples: PIQRAY, QINLOCK, many molecular target inhibitors list PA and QL.
• Tier 5 oral oncology drugs are commonly subject to PA and QL.

PA required for many specialty drugs

Numerous specialty drugs throughout the formulary require prior authorization (PA); providers should review each drug entry for a PA flag and submit authorization requests accordingly.

• Specialty oral oncology and other Tier 5 products routinely indicate PA in Requirements/Limits.
• See the drug listing for product‑specific PA and QL values.

Prior authorization required (examples: VERSACLOZ, LIVTENCITY, PREVYMIS)

Certain high-cost or specialty agents are explicitly listed with 'PA' (examples include VERSACLOZ, LIVTENCITY, PREVYMIS); providers must obtain PA for these products to secure coverage.

• VERSACLOZ — PA; QL (540 mL per 30 days).
• LIVTENCITY — PA; QL (336 EA per 28 days).
• PREVYMIS (oral packet/tablet) — PA; QL (120 EA per 30 days).

Prior authorization required for listed items (examples)

Several listed devices, injectables, and supply items require prior authorization (PA) per the formulary entries; obtain PA for those items listed with 'PA' to avoid claim denials.

• Examples include TRULICITY auto‑injector (PA; QL 2 mL/28 days) and various pen needles/syringes listed with PA.
• Some supplies and devices show PA in Requirements/Limits.

Prior authorization required for select drugs (NEXLETOL, REPATHA examples)

Prior authorization is required for select cardiovascular/lipid agents and biologics shown with 'PA' (examples include NEXLETOL, NEXLIZET, REPATHA variants); submit PA requests per the formulary entry.

• NEXLETOL/NEXLIZET — PA; QL (30 EA per 30 days).
• REPATHA and REPATHA PUSHTRONEX — PA with specified QLs (2 mL per 28 days; 3.5 mL per 30 days).

Prior Authorization Required (general reminder to providers)

This is a reminder that prior authorization (PA) is required where indicated on the formulary; providers must obtain PA before dispensing to ensure coverage.

• Check the Requirements/Limits column on each drug line for 'PA'.
• Failure to obtain PA may result in noncoverage.

Prior authorization required (examples across chunks)

Multiple formulary examples across sections show PA flags; providers must submit prior authorization requests for those products (see product lines for exact PA/Q L annotations).

• Sodium channel agents group — PA; QL examples shown.
• Eslicarbazepine acetate and many anticonvulsants have PA noted.

Prior Authorization requirement for Tier 5 specialty and branded products

Prior authorization is required for many Tier 5 specialty and branded products; providers must secure PA prior to dispensing these specialty medications to avoid coverage denial.

• Cosentyx, Dupixent, Skyrizi and other biologics show PA with QL.
• Tier 5 specialty products are frequently PA‑controlled and limited to 30‑day supplies.

PA required for select specialty agents

PA is required for a broad set of specialty agents identified in the formulary; providers must request PA for those agents flagged with 'PA' to obtain plan coverage.

• Examples include BILPREVDA, EVENITY, TERIPARATIDE, TYMLOS — shown with PA and/or QL.
• Specialty/high‑cost agents listed with PA will not be covered without authorization.

Prior authorization required for specified specialty agents

Selected pulmonary, cystic fibrosis, pulmonary hypertension and pulmonary fibrosis agents are listed with 'PA' — providers must obtain prior authorization for these specified specialty agents before coverage.

• CAYSTON, KALYDECO, ORKAMBI, TRIKAFTA — PA; many with QL and some with LA.
• Pulmonary antihypertensives (ADEMPAS, ambrisentan, bosentan, etc.) list PA; QL values provided.

Step therapy requirement (overview)

Step therapy (ST) may require that the member try specified lower‑step drugs before an alternative will be covered; providers must follow ST requirements where indicated on the formulary.

• ST is shown in the formulary abbreviations and applies when 'ST' is listed next to a drug.
• Providers should document prior agent failure or intolerance when requesting exceptions.

Step Therapy (general requirement)

Some drugs are subject to step therapy (ST); members must try specified first‑line drugs before alternatives are covered and providers should submit documentation showing prior trials.

• ST is used where indicated in the Requirements/Limits column (e.g., FETZIMA lists ST).
• If step requirements are not met, coverage may be denied.

Step therapy for DIFICID

DIFICID (fidaxomicin) oral suspension and tablets are listed with Step Therapy (ST) and quantity limits; providers must follow the ST requirement and request PA if required.

• DIFICID oral suspension — ST; QL 136 mL per 10 days.
• DIFICID oral tablet — ST; QL 20 EA per 10 days.

Step therapy applies where indicated (examples)

Step therapy applies to specific agents where 'ST' is indicated (examples include FETZIMA, TRINTELLIX, eletriptan); providers must ensure required prior therapy has been tried or submit an exception.

• FETZIMA — ST; QL 30 EA per 30 days.
• Eletriptan — ST; QL (6 EA per 30 days).

Step therapy (conditional) — legend reference

The formulary legend defines 'ST' (Step Therapy); where ST is shown next to a drug, step therapy requirements apply though specific sequences are not always enumerated in these chunks.

• ST is an abbreviation in the formulary legend and applies when shown next to individual products.
• Specific step sequences may be defined in separate PA/clinical criteria documents.

Step therapy present for select agents (paliperidone ER example)

Paliperidone ER formulations are listed with Step Therapy (ST) and quantity limits; prescribers must follow ST requirements for these formulations.

• Paliperidone ER — ST; QL (30 EA per 30 days for some strengths; 60 EA for others).
• Document previous therapy or reasons for exception when requesting coverage.

Step therapy presence (general)

Step therapy is present as a plan control (ST) and may apply to a variety of agents; providers should check the drug line for an ST flag and comply with step requirements or request an exception.

• ST appears across multiple sections and is part of the Requirements/Limits legend.
• If ST applies and is not followed, claims may be denied.

Prescriber supporting statement and timelines for exceptions

Where a prescriber requests an exception to a coverage restriction (PA, QL, ST), the prescriber must provide a supporting medical statement describing why the exception is needed; standard decisions are made within 72 hours and expedited requests within 24 hours.

• Prescriber must explain medical reasons for the exception.
• Standard decision timeframe: 72 hours; expedited: 24 hours when appropriate.

Medicare Part B vs D documentation note

Formulary entries marked 'B/D' indicate Part B vs Part D coverage may apply and the prescriber may need to submit documentation describing the drug use and setting to determine the correct Medicare benefit.

• B/D designation signals potential Part B (medical) vs Part D (drug) determination.
• Provider documentation about use and site-of-care may be required for benefit determination.

Home infusion documentation requirement note

Products designated 'HI' (Home Infusion) may be covered under the medical benefit and require documentation supporting home infusion services; providers should supply documentation for HI‑designated IV/reconstituted formulations.

• Examples of HI designations include vancomycin IV reconstituted strengths and cefazolin, cefepime, ceftazidime, ceftriaxone.
• Contact Customer Care for medical‑benefit/home infusion coverage details.

Quantity limits require supporting documentation

Quantity limits (QL) are applied to many products; providers must document the prescribed quantity and indication when requesting quantities that approach or exceed the listed QL.

• Examples: Sodium Channel Agents group — QL 1100 mL per 30 days; donepezil 10 mg — QL 60 EA per 30 days.
• Exceeding QL may require PA or lead to denial.

Documentation for PA-listed drugs

When 'PA' is listed in the Requirements/Limits field for a drug, prior authorization documentation must be submitted to support coverage; PA requests should include drug name, strength, quantity, and clinical rationale.

• PA requests should reference the formulary Requirements/Limits for the specific product.
• Include clinical justification and prior therapy history when applicable.

Documentation for PA (prescriber must specify details)

Prescribers must specify drug, strength, quantity and relevant clinical details when requesting prior authorization; pharmacy claims should document PA and adhere to the drug's QL.

• Document PA approval and QL on pharmacy claims for audit and payment.
• Provide clinical details (diagnosis, prior therapies, dosing) in PA requests.

Document PA and QL on claims

Document prior authorization approvals and quantity‑limit justifications on claims; for products with QL (e.g., REPATHA 2 mL per 28 days) ensure the claim reflects the authorized quantity and PA information.

• Pharmacy claims should include PA identifiers and match QL limits.
• Examples: REPATHA variants show PA and specific mL QLs that must be observed on claims.

Formulary abbreviations (reference for providers)

Formulary abbreviations (PA, QL, ST, ED, HI, B/D, LA, NE) are defined in the legend and must be referenced when submitting authorization requests or documentation.

• PA = Prior Authorization; QL = Quantity Limits; ST = Step Therapy; ED = Excluded Drug; HI = Home Infusion; B/D = Part B vs Part D.
• Use the Requirements/Limits field as the basis for authorization documentation.

Not obtaining required prior authorization may result in noncoverage

Not obtaining a required prior authorization may result in the plan not covering the drug; providers should secure PA to avoid noncoverage or denial of claims.

• The formulary states that without PA, Priority Health Medicare may not cover the drug.
• Providers should verify PA status prior to dispensing.

Prior Authorization Risk — missing PA may trigger denial

Failure to obtain prior authorization where required may lead to claim denial or noncoverage by Priority Health Medicare for the listed drug.

• PA is required for many specialty/Tier 5 drugs; missing PA can trigger denial.
• Members or prescribers may request an exception, but PA remains required unless exception approved.

Prior Authorization triggers for specific products (XIFAXAN example)

Specific products trigger prior authorization (e.g., XIFAXAN 200 mg and 550 mg require PA and have QLs); lack of PA for these products may lead to noncoverage.

• XIFAXAN 200 mg — PA; QL 9 EA per 30 days.
• XIFAXAN 550 mg — PA; QL 60 EA per 30 days.

Prior authorization required for listed agents — denial risk

Many listed specialty agents will be denied if PA is not obtained (examples across the formulary include NEXLETOL, NEXLIZET, REPATHA and multiple specialty neurology, oncology, and pulmonary agents).

• REPATHA variants — PA required; QL specified.
• Specialty T5 drugs commonly require PA and may be denied without it.

Step therapy may trigger denial if not followed

Failure to follow step therapy requirements (where 'ST' is indicated) may result in denial of coverage for the requested drug; providers should verify and document prior treatment attempts or request an exception.

• Examples: FETZIMA and eletriptan list ST and QL.
• If ST is not met, submit clinical rationale for exception.

Prior Authorization required for oncology oral drugs — denial risk

Many oncology oral drugs listed as Tier 5 require prior authorization and claims may be denied without PA; providers must secure PA prior to dispensing these oral oncology agents.

• Examples: ERLEADA, XTANDI, PIQRAY, QINLOCK and many molecular targeted therapies show PA; QL applies.
• Tier 5 oral oncology agents are frequently PA‑controlled.

Prior Authorization required — missing PA may trigger denial

Prior authorization (PA) is required for numerous listed drugs; absence of PA documentation on the claim may result in denial or noncoverage of the medication.

• VERSACLOZ, LIVTENCITY, PREVYMIS are examples of drugs requiring PA where coverage may be denied without it.
• Check each product's Requirements/Limits for PA and QL details.

Quantity limit triggers — exceeding QL may lead to denial

Quantity limits (QL) are enforced for many products; claims requesting quantities above the listed QL may be denied or require additional review and supporting documentation.

• Examples: AMVUTTRA — QL 0.5 mL per 90 days; ENDARI — QL 180 EA per 30 days; VYNDAMAX — QL 30 EA per 30 days.
• Exceeding QL generally requires PA or clinical justification.

Prior authorization triggers for specified branded specialty agents

Prior authorization is required for many branded specialty agents (examples include LUPRON DEPOT kits, SIGNIFOR, SOMAVERT, TRELSTAR MIXJECT); secure PA to obtain coverage for these products.

• LUPRON DEPOT (1‑month and 3‑month kits) — PA.
• SIGNIFOR and SOMAVERT — PA noted in Requirements/Limits.

Quantity limit triggers (biologic mL examples)

Exceeding quantity limits for biologics and injectables (e.g., COSENTYX 8 mL/28 days; DUPIXENT mL per 30 days) can result in denial or restricted coverage; adhere to the QL listed on each drug line.

• COSENTYX 300 mg — PA; QL 8 mL per 28 days.
• DUPIXENT — PA; QL varies by presentation (e.g., 3.42 mL or up to 8 mL per 30 days).

Exclusion denial risk for ED‑listed drugs (benz onatate example)

Benzonatate is listed as an Excluded Drug (ED) on the formulary; claims for excluded drugs may be denied and are not normally covered by the Medicare prescription drug benefit.

• ED = Excluded Drug; benzonatate is specifically marked ED in the respiratory agents section.
• Excluded drugs do not count toward catastrophic coverage and are not normally covered.

Document home infusion (HI) eligibility and supply requirements

Products marked 'HI' (Home Infusion) indicate potential medical benefit coverage and may require documentation supporting home infusion services; contact Customer Care for specifics.

Document HI designation for IV/reconstituted formulations

Multiple intravenous/reconstituted formulations are designated HI; providers must document home infusion needs and may need to bill through the medical benefit when HI applies.

Use B/D and HI flags to determine site/benefit and document accordingly

B/D and HI annotations influence site-of-care and benefit determination; when these flags appear, providers must document the setting and follow billing guidance for Part B or medical coverage.

Document site-of-care when HI affects delivery/billing

Home infusion designation (HI) may change where therapy is delivered and billed (medical benefit vs pharmacy); providers should document site-of-care to support correct billing.

B/D and HI flags affect billing and site-of-care

B/D and HI annotations affect site-of-care and billing; products marked HI may be covered under the medical benefit and require home infusion documentation and billing to the appropriate benefit.

Home infusion designation affects delivery and billing

Home infusion (HI) designation indicates medical‑benefit coverage for certain IV/infusion products; providers must document home infusion needs and follow medical‑benefit billing rules when HI applies.

Formulary may add biosimilars and re‑tier originals — monitor updates

Plan may immediately add interchangeable biosimilars and re‑tier original biologicals; providers should be aware that formulary versions can change and review updates on the plan website.