No prior authorization required for:
- Emergency room
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Praluent authorization criteria
Priority Health authorizes the PCSK9 drug class (Praluent® and Repatha®) when used for homozygous and heterozygous familial hypercholesterolemia.
A patient must meet Priority Health prior authorization criteria before coverage is provided.
Not authorized for:
- Diagnoses of clinical atherosclerotic cardiovascular disease and other conditions
- Patients without familial hypercholesterolemia
- Medicaid and Healthy Michigan Plan members
Authorization denials automatically refer your patients to a clinic
When your request for a PCSK9 inhibitor authorization is denied, it triggers a denial letter to the patient which also offers a referral to a Lipid Management Clinic. We also call the member to offer this referral. We notify you when we make this offer to your patient.
If we call and/or write or email your patient about the option of visiting a Lipid Management Clinic:
- We provide your patient with a list of clinics.
- We suggest a virtual visit with the Spectrum Health Grand Rapids clinic if they live too far from a physical clinic.
Once your patient lets us know their preference, Priority Health will make a referral, faxing or emailing the patient's information and history to the clinic.