Some drugs have rules or requirements
Some covered drugs have additional requirements or limits on coverage before a Priority Health Medicare Advantage plan will pay for them. Use these tools to help you determine if and what types of rules or requirements your drug may have.
To find each drug's specific requirements
You can use our online formulary, the "Approved Drug List," to look up a drug to see if there are requirements that you try other drugs first, or get prior authorization, or any other coverage detail.
Common requirements and rules
When you use the Approved Drug List to look up a drug, you may see abbreviations next to it indicating a restriction or limitation on how and when Priority Health will cover it. Below is our key to those requirements and limitations.
B/D: Part B vs. Part D coverage
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.
HI: Home infusion
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).
LA: Limited availability
This prescription may be available only at certain pharmacies.
QL: Quantity limits
For some drugs, Priority Health Medicare limits the amount, or quantity, that you can get from a pharmacy at one time. For example, ELIQUIS® has a quantity limit of 74 tablets per 30 days. This may be in addition to a standard one-month or three-month supply limit.
PA: Prior authorization
Priority Health requires you or your physician to get pre-authorized 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 up front, your Priority Health Medicare Advantage plan may not cover the drug.
Here's a list of the drugs that require PA and the criteria for approval for each of them.
ST: Step therapy
A step therapy requirement means that, in some cases, we may require 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, your plan may not cover Drug B until you first try Drug A. If Drug A does not work for you, Priority Health Medicare may then cover Drug B.
Here's a list of the drugs that require ST and what drugs you'll need to try first before they are approved for you.