From formulary to prior authorization—your questions are answered

From formularies to specialty drugs, your pharmacy spend can raise the most questions. The following FAQs are designed to answer some of yours:

What is a formulary?

A formulary is an approved list of covered drugs. Each insurance carrier creates and administers their own unique formulary.

How does Priority Health determine its formulary?

Our Pharmacy and Therapeutics Committee reviews our approved drug list carefully. The committee includes doctors, pharmacists and other health care professionals from our network who meet six times a year to research and review the newest drugs on the market—and they all have your employees' budgets and health needs in mind.

Where can employees find the formulary?

At the bottom of our homepage, they can click the "Approved Drug List" button, select their plan type and review their formulary.

Is there a way my employees can see how much they might pay for a drug before they fill the prescription?

We urge employees to use Cost Estimator, our digital pricing tool that tells members what they can expect to pay for procedures and prescriptions. Employees can find the tool in their member profile or on the Priority Health app.

Why do some drugs have additional requirements before members can get them?

There are a variety of reasons why this may occur, but the biggest reasons are the following:

Quantity limits

Certain medications may have monthly quantity limits (QL).

Prior authorization

Prior authorization (PA) happens when you need an approval from your insurer prior to receiving a drug. PA forms are available on our homepage or, in many cases, doctors can submit a request by calling or faxing Priority Health.

Step therapy

Step therapy is a type of prior authorization that requires employees to try similar or generic versions of a specific drug before that drug is approved. It’s designed to save employees money using safe alternatives to expensive drugs. However, if the lower cost alternative isn’t effective, doctors can work with us to request an exception. 

Transition fill exception

If you are new to Priority Health, you and your employees may need additional time to work with doctors for medications that require our prior authorizations. If employees require drugs not worked out in their new plan, most drugs can be filled one time without requirements if they're filled within 120 days of the new plan start date.

Member Pay Difference (MPD)

This is the difference employees pay if they choose to use a non-preferred brand name drug over a lower cost generic equivalent. The amount does not apply to the employee’s deductible or out-of-pocket maximum and may include the applicable copay for the brand name drug.

What are drug tiers?

Tiers group prescription drugs by cost and value, with generic drugs most often being the least expensive. Insurance carriers categorize drugs into tiers according to their approved drug list, meaning no two are alike from carrier to carrier. Here are some examples:

  • Preferred brand drugs can cost more than generics but often have a lower copayment than non-preferred brand drugs.
  • Non-preferred brand drugs generally cost more than preferred brand drugs.
  • Preferred specialty drugs are generally self-administered and have special handling or training requirements.
  • Non-preferred specialty drugs generally cost more than preferred specialty drugs.
  • Excluded drugs are those not covered by your insurance carrier and are not covered for any reason.