Search our online formulary tools to understand drug coverage information by plan, including formulary status for a specific drug and utilization management rules like 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:
For drugs listed on our Medical Drug Lists (MDLs), providers can submit coverage determination requests, reconsiderations, and appeals to the Pharmacy Department through one of the following methods listed below:
- Fax: Send your completed fax forms to 877.974.4411
- Web form
Out-of-network authorization process for providers
If you are out-of-network with a member’s Priority Health plan, you must submit an out-of-network (OON) authorization request through prism before providing services. Outpatient facilities or home infusion agencies that will be administering a drug and are out-of-network must also obtain an out-of-network (OON) authorization through prism before the drug request can be submitted or reviewed.
- Out-of-network providers: Review the section on "How to request an authorization" for all other procedures/services – outpatient.
- Out-of-state providers: Review the section on "How to request an authorization" for all other procedures/services – outpatient.
- Once the out-of-network (OON) authorization has been reviewed and approved in prism, you may then submit any drug requests to the Pharmacy Department for a coverage determination.
Submitting these requests incorrectly could lead to inaccurate denials or an increase in response time from our teams.
Drugs covered under the medical benefit
You can find general medical drug information for medications covered under the medical benefit and submitted as part of professional and institutional (CMS 1500, UB-04) claims on our medical benefit drug information page.
Use our Medical Drug Lists (MDLs) to find coverage details for specific drugs, including any applicable utilization management criteria. Drug coverage and criteria differ by plan type.
We want your feedback. If you have comments or suggestions to improve the MDL user experience, please send them to:
ph-pharmacybusinessopswebsite@priorityhealth.com.
Drugs covered under the pharmacy benefit
Use our Approved Drug Lists (ADLs) to find coverage details for specific drugs, including any applicable utilization management criteria. Drug coverage and criteria differ by plan.
Drug request forms and prior authorization criteria
Drug request forms and prior authorization criteria can be found below by plan type.