Priority Health Prior Authorization Lookup
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Latest Priority Health prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-20Employer Group Pharmacy Prior Authorization Criteria (partial)This document defines prior authorization requirements and coverage criteria for pharmacy drugs under Priority Health employer group plans; it is intended for providers submitting pharmacy prior authorization requests and for plan administrators referencing the Approved Drug List (ADL).All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Medicare Part B Prior Authorization and Step Therapy Criteria (July 2026)Governs prior authorization and step therapy requirements for Medicare Part B drugs administered by providers under Priority Health Medicare; affects providers submitting PA/ST requests and billing for Part B drugs.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Prior Authorization Criteria — pharmacy & specialty drugs (alphabetical drug list)This document lists prior authorization requirements, exclusions, required documentation, age/prescriber restrictions, coverage durations, and prerequisite therapy rules for multiple pharmacy and specialty drug products. It applies to providers requesting coverage under the payer's drug benefit.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Priority Health Medicare Part B prior authorization and step therapy criteria for Part B drugsThis document governs prior authorization (PA) and step therapy (ST) requirements for Medicare Part B outpatient drugs and biologics administered by providers, and guides providers on use of the Medical Drug List (MDL) and Medicare coverage resources.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Priority Health Medicare Prior Authorization Criteria — Pharmacy & Specialty DrugsMedicare prior authorization criteria for pharmacy and specialty drugs for Priority Health members, organized alphabetically by drug with indication-specific requirements, exclusions, documentation, duration, and utilization controls.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-20Prior Authorization Criteria — Pharmacy & Specialty DrugsThis document lists prior authorization requirements, exclusions, documentation, age and prescriber restrictions, coverage durations, and renewal criteria for numerous pharmacy and specialty drugs covered by Priority Medicare Dual Premier (HMO D-SNP). It affects prescribers and pharmacy adjudicators seeking authorization for the listed products.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-20Priority Health Medicare Prior Authorization Criteria — Pharmacy & Specialty DrugsGoverns prior authorization, coverage duration, exclusions, required documentation, and clinical prerequisites for specified pharmacy and specialty drugs for Priority Health Medicare members. Affects prescribers requesting coverage for listed products.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-20Priority Health Medicare Prior Authorization Criteria — Pharmacy & Specialty DrugsLists prior authorization, coverage, exclusion, and documentation requirements for many pharmacy and specialty drugs for Priority Health Medicare products and applies to providers requesting authorization for these drugs.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01CELLULAR AND GENE THERAPYDefines Prior Authorization, provider, facility, coding, and coverage considerations for cellular and gene therapy products (including CAR-T) and applies to Priority Health members according to their benefit plans.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Genetics: Counseling, Testing, ScreeningCoverage criteria for genetic counseling, testing, and screening services for Priority Health members, including medical necessity, prior authorization, and services managed through eviCore. Applies to providers ordering or performing genetic services for affected members.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01MODERATE SEDATION FOR INTERVENTIONAL PAIN MANAGEMENTThis policy defines when moderate (conscious) sedation or anesthesia for adults undergoing interventional pain management procedures is considered medically necessary and when it is not, and describes coding and prior authorization considerations for providers and payers.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare 2026 Formulary (Drug List) - Coverage CriteriaThis document is the 2026 formulary (drug list) for Priority Health Medicare, describing covered drugs, applicable restrictions (prior authorization, quantity limits, step therapy), member rights to exceptions and transitions, and how to use the formulary. It affects plan members, prescribers, and network pharmacies using Priority Health Medicare benefits.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare 2026 Formulary (Drug List) - Coverage CriteriaThis document is the Priority Health Medicare formulary (Drug List) that describes covered prescription drugs, coverage rules (prior authorization, step therapy, quantity limits), member rights to exceptions and transition supplies, and how to use the formulary. It affects Priority Health Medicare members, prescribers, and network pharmacies.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare Employer Group Formulary (Drug List) — Coverage CriteriaDefines the covered prescription drugs, formulary structure, restrictions (prior authorization, quantity limits, step therapy), and exception/transition processes for Priority Health Medicare Employer Group members.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Priority Health Medicare MPSERS Formulary (Drug List)This document is the Priority Health Medicare MPSERS formulary describing covered prescription drugs, coverage rules (prior authorization, step therapy, quantity limits), member protections, and how to request exceptions; it affects Priority Health Medicare MPSERS plan members and their prescribers and pharmacies.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Solid organ transplant prior authorization formA prior authorization request form to be completed by providers seeking authorization for solid organ transplant services (listing, admission, and transplant procedures) for Priority Health members. It captures member, diagnosis, transplant type, dates, provider and facility identifiers, and notes that Priority Health's transplant policy #91272 applies for certain organs.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-21Priority Health Medicare MPSERS Formulary (Drug List) - Coverage CriteriaDescribes the prescription drugs covered by the Priority Health Medicare MPSERS plan, applicable rules (prior authorization, quantity limits, step therapy), and how members and prescribers can request exceptions or transition supplies.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Medicare Part B Prior Authorization and Step Therapy CriteriaDefines prior authorization and step therapy requirements for Medicare Part B (medical) drugs administered by providers, including criteria, exclusions, documentation, and product-specific rules for Priority Health Medicare Advantage enrollees.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Priority Health Medicare 2026 Formulary (Drug List) — Coverage CriteriaThis document is the 2026 formulary for Priority Health Medicare describing covered Part D drugs, coverage rules (prior authorization, step therapy, quantity limits), and how members and prescribers can request exceptions or transition supplies. It affects Priority Health Medicare members and network providers who prescribe or dispense prescription drugs under the plan.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Priority Health Medicare Formulary (2026) - Drug List / Coverage CriteriaThis document is the 2026 Priority Health Medicare formulary (drug list) describing covered drugs, restrictions (prior authorization, quantity limits, step therapy), member rights to exceptions, and how to use the formulary. It affects Priority Health Medicare members and their prescribers/pharmacies.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Priority Health Medicare MPSERS Formulary (Drug List) — Coverage CriteriaThis document is the Priority Health Medicare MPSERS formulary (Drug List) describing covered drugs, coverage rules, restrictions (prior authorization, step therapy, quantity limits), member rights to exceptions and transition supplies, and how members/providers can find formulary information. It affects Priority Health Medicare MPSERS plan members and their prescribers/pharmacies.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Priority Health Medicare MPSERS Formulary (Drug List) — Coverage CriteriaThis 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.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Chelation Therapy Coverage CriteriaEstablishes Priority Health coverage criteria, applicable diagnoses, documentation, coding, and prior authorization considerations for chelation therapy; applies to Priority Health members and providers delivering care under covered plans.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01GENETICS: COUNSELING, TESTING, SCREENINGDefines Priority Health coverage criteria for genetic counseling, testing, and screening services, including medical necessity, prior authorization via Evicore for select tests, and management of specific tests; applies to Priority Health members and their providers.All priority health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01INFUSION SERVICES AND EQUIPMENTDefines medical necessity, prior authorization, coding, and regulatory guidance for external and implantable infusion pumps and related supplies for Priority Health members; applies to clinical providers and DME suppliers contracting with the payer.All priority health updates
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Tool Description
Search Priority Healthprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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