Drug coverage requirements key
You may have noticed your drug has abbreviations next to it indicating a restriction or limitation on the amount of a drug you can get. Below is our key, which defines your drug(s) limitations.
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. For more information, consult your Pharmacy Directory (PDF).
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.