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. Go to the online Approved Drug List now.

Drug coverage requirements key

When you check the Medicare formulary, you may notice your drug has abbreviations next to it indicating a restriction or limitation on the amount of a drug you can get. Here are explanations of the types of limitations there are on some of the drugs covered for you.

Part B vs. Part D (B/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.

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).

Limited availability (LA)
This prescription may be available only at certain pharmacies. 

Quantity limits (QL)
Priority Health Medicare limits the amount that we will cover on some drugs. For example, we have a quantity limit of 60 tablets per 30 days for ELIQUIS. This may be in addition to a standard one-month or three-month supply.

Prior authorization (PA)
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.

Step therapy (ST)
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 will then cover Drug B.