FAQs About Approved Drugs

Click any question to find the answer below.

Do PriorityMedicare plans cover all prescription drugs?

What is a formulary?

Can a formulary change?

How do I use a formulary?

How much will I pay for covered drugs?

What are generic drugs?

Are there any other restrictions on coverage?

What do I do if my drug is not on the formulary?

How do I request an exception to the formulary?

Do PriorityMedicare plans cover the same drugs as Medicare Part B or Part D?

What types of drugs might be covered under Medicare Part B?

What is a Medication Therapy Management (MTM) program?


Q: Do PriorityMedicare plans cover all prescription drugs?
No. PriorityMedicare plans use a formulary, which is a list of approved drugs. Some drugs included on a formulary may have additional requirements for or limits on their coverage, such as prior authorization, step therapy (steps you must take before we approve the drug for you), or limits on quantities. Our committee of doctors and pharmacists reviews all drugs for how effective they are, and periodically makes changes to the formularies. If a formulary changes and a drug you are taking is removed, you will be notified in writing before the change is made.
View the current PriorityMedicare formularies


Q: What is a formulary?
A formulary is a complete list of all the prescription drugs that are approved for coverage by a member's plan. All PriorityMedicare plans - PriorityMedicare, PriorityMedicarePlus, and PriorityMedicareRx - use one formulary for individuals who purchase these plans. There's another, slightly different, formulary used by employer groups who purchase any PriorityMedicare plan for their employees and retirees. We will generally cover the drugs listed in our formularies as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, see the FAQs on filling prescriptions.

Q: Can a formulary change?
Yes, Priority Health may add or remove drugs from the PriorityMedicare formularies during the year. The formularies on this website are current as of January 1, 2007. To get updated information about what drugs are covered, see the Pending Changes notice on this website or contact us directly. If we remove drugs from our formulary during the year, we must notify you of the change at least 60 days before the date that the change becomes effective.


Q: How do I use a formulary?
There are two ways to find your drug within a formulary:

• Medical Condition: The drugs in the formulary are grouped into categories depending on the type of medical conditions that they are used to treat.  For example, drugs used to treat a heart condition are listed under the category, "Cardiovascular Agents." If you know what your drug is used for, look for the category name in the list in section 2. Then look under the category name for your drug.
• Alphabetical Listing: The Index in section 2 provides an alphabetical list of all of the drugs included in the formulary. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Find that page and find the name of your drug in the first column of the list.

Go to the Formulary section of this website.


Q: How much will I pay for covered drugs?
The plan you choose, whether PriorityMedicare, PriorityMedicarePlus, or PriorityMedicareRx, will pay part of the costs for your covered drugs and you will pay part. Plan benefits vary when offered through an employer. If you qualify for extra help with your drug costs, the costs for your drugs may be different.
Learn more about extra help for people with limited incomes or resources.
Go to drug cost information for PriorityMedicare and PriorityMedicarePlus medical + prescription plans
Go to drug cost information for PriorityMedicareRx prescription drug plan.


Q: What are generic drugs?
PriorityMedicare plans all cover both brand-name drugs and generic drugs. A generic equivalent has the same active ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as their brand-name counterparts.


Q: Are there any other restrictions on coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: PriorityMedicare plans may require prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, the PriorityMedicare formularies limit the amount of the drug that we will cover. For example, the formularies limit Imitrex to 18 tablets per prescription.
• Step Therapy: In some cases, your PriorityMedicare plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we may then cover Drug B.

You can find out if your drug has any additional requirements or limits by finding it in the formulary.

You can ask your PriorityMedicare plan to make an exception to these restrictions or limits. See the question, "How do I request an exception to the formulary?" below.


Q: What do I do if my drug is not on the formulary?
If you join a PriorityMedicare, PriorityMedicarePlus or PriorityMedicareRx plan and find that your drug is not included in its formulary, you should first call us and verify that your drug is not covered. If it is not covered, you should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

One 31-day transition supply may not give you sufficient time to talk to your doctor and review alternatives when you join one of our plans. Therefore, we may cover up to a maximum of one 90-day supply OR three 31-day transition supplies per non-formulary medication or formulary medication requiring step therapy during a single transition event in your first 90 days covered by our plan. After that, we will no longer pay for your non-formulary drug.

More help:

• Find detailed information about your prescription drug coverage in the Evidence of Coverage and other plan materials.
• Ask Customer Service for a list of similar drugs that are covered by your plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered.
• You can ask PriorityMedicare, PriorityMedicarePlus, or PriorityMedicareRx to make an exception and cover your drug (see below).
  
  

Q: How do I request an exception to the formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on the formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, PriorityMedicare, PriorityMedicarePlus and PriorityMedicareRx limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Tier 3 (non-preferred brand name) drug, you can ask us to cover it as a Tier 2 (preferred brand name) instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on the formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, all our plans will only approve your request for an exception if the alternative drugs included on the plan's formulary or the lower-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask for an initial coverage decision for a formulary or tiering exception. When you are requesting a formulary or tiering exception, you should send us a statement from your doctor supporting your request. Generally, we must make our decision within 72 hours of your request.


Q: Do PriorityMedicare plans cover the same drugs as Medicare Part B or Part D?
Our medical plans, PriorityMedicare and PriorityMedicarePlus, cover both Medicare Part B prescription drugs and Part D prescription drugs. Copayments and limitations may apply.

The PriorityMedicareRx plan does not cover drugs that are covered under Medicare Part B. Generally, it only covers drugs that are covered under the Medicare prescription drug benefit (Part D) and that are on our formularies. Copayments and limitations may apply.


Q: What types of drugs might be covered under Medicare Part B?
The following outpatient prescription drugs may be covered under Medicare Part B.

• Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
• Osteoporosis Drugs: Injectable drugs for osteoporosis provided by home health agencies under certain conditions.
• Erythropoientin (EPO): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
• Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
• Injectable Drugs: Most injectable drugs administered incident to a physician's service.
• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
• Some Oral Cancer Drugs: If the same drug is available in injectable form.
• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugs provided through DME.
  
  

Q: What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program helps us ensure that our members with multiple chronic conditions, such as asthma and heart disease, and who are taking multiple covered drugs use them in ways that get the best results. You may be asked to participate in an MTM program designed for your specific health and pharmacy needs. We recommend that you take full advantage of this program if you are selected. Read more about the MTM program.