For drugs covered under the medical benefit
Reference the Medical Benefit Drug List (MBDL) (formerly the Injectable Drug List) to view coverage details for medications that are covered under the medical benefit. Forms for drugs that require authorization are linked in the MBDL.
For 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.
General drug request forms
Fax completed forms to Priority Health at 877.974.4411.Use these general forms when there is no drug-specific form listed.
General non-Medicare forms
- Pharmacy drug request
- Oral oncology drug request
- Medical drug request
- Oncology medical drug request
- Quantity limit exception request form
- Dispense as Written (DAW)
General Medicare prior authorization information
- Medicare Part D prior authorization criteria
- Medicare Part D coverage determination request form
- Medicare Part B prior authorization form
- Medicare Part B oncology prior authorization form
- Medicare Part B vs Medicare Part D coverage determination form
- Hospice/Part D drug prior authorization form
- Medicare prescription drug request for redetermination (appeal) form