Drug information

Search our online formulary tools to understand drug coverage information by plan, including formulary status for a specific drug and if there are utilization management rules such as prior authorization requirements, step therapy requirements, age limits and/or quantity limits.

Submitting drug coverage authorization requests, reconsiderations and appeals

When submitting drug coverage authorization requests, reconsiderations and appeals, follow the guidelines below. 

For pharmacy drugs:
All pharmacy drug coverage authorization requests, reconsiderations and appeals should be submitted to the Pharmacy department through one of the following methods:

• Fax: Send your completed fax forms to 877.974.4411
• Electronic prior authorization (ePA)
• Phone: Call 800.466.6642
• Mail (for Medicare appeals only)
  Mail to: Priority Health Appeals Coordinator - MS1260
  1231 East Beltline Ave NE
  Grand Rapids, MI 49525

For medical drugs:
If the drug is listed on our Medical Benefit Drug List (MBDL), all coverage authorization requests, reconsiderations and appeals should be submitted to the Pharmacy department through one of the methods listed above. You can find the MBDL below. 

If the drug isn’t listed on our MBDL, all drug coverage authorization requests, reconsiderations and appeals should be submitted through prism.

Submitting these requests incorrectly could lead to inaccurate denials or an increase in response time from our teams. 

Drugs covered under the medical benefit

View general medical drug information for medications that are covered under the medical benefit and submitted as part of professional and institutional (CMS 1500, UB-04) claims.

Coverage for medication and any applicable utilization management criteria can be found on the Medical Benefit Drug List (MBDL). Since coverage and criteria differ by plan, filter for the plan type to view the applicable information. Forms and the utilization management criteria for drugs that require authorization are linked in the MBDL.

Medical Benefit Drug List (MBDL)

Drugs covered under the pharmacy benefit

Coverage for medication and any applicable utilization management criteria can be found on the Approved Drug Lists. Since coverage and criteria differ by plan, choose the plan type to view the correct plan-approved drug list.

Drug request forms and prior authorization criteria

Drug request forms and prior authorization criteria can be found below by plan type. 

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