Some drugs have limitations on coverage

Some covered drugs have additional requirements or limits on coverage before a Priority Health Medicare plan will pay for them. These requirements and limits may include:

• Part B vs. Part D (B/D): You'll pay for some drugs differently depending on whether they are covered by your medical plan (Medicare Part B, you pay 20% coinsurance) or your drug plan (Medicare Part D, you pay your prescription copay). It depends on the use and setting of the drug.
  Learn more about what drugs are covered by Medicare Parts A, B and D. 
• Home infusion (HI): This means that the prescription drug may be covered under your medical benefit (Part A or B) instead of your prescription drug plan (Part D). For more information, call Customer Service at 888 389-6648, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.
• Limited availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at toll-free 888 389-6648, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.
• Prior authorization (PA): Priority Health Medicare requires you or your physician to get pre-authorized for certain drugs. This means that you will need to get approval from Priority Health Medicare before you fill your prescriptions. If you don't get approval up front, Priority Health Medicare may not cover the drug. Click the "Prior authorization" link in the left column to see a list.
• Quantity limits (QL): Priority Health Medicare limits the amount that we will cover on some drugs. For example, we have a quantity limit of 18 tablets per prescription for Maxalt. This may be in addition to a standard one-month or three-month supply.
• Step therapy (ST): A step therapy requirement on a drug is a requirement to try a different/alternate drug first. For example, if Drug A and Drug B both treat your medical condition, Priority Health Medicare may not cover Drug A until you first try Drug B. If Drug B does not work for you, Priority Health Medicare will then cover Drug A. Click the "Step therapy" link in the left column to see a list.

To find each drug's specific limitations

You can use an online tool called "Approved Drug List" to look up any drug to see if there are requirements that you try other drugs first, or get prior authorization, or any other coverage detail.
Go to the online Approved Drug List now.

Your doctor or other health care provider may need the following information.

These forms are available on the provider section of priorityhealth.com.

• Prior authorization forms for drugs 
• Coverage Determination Request form (237KB PDF)