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:
If the drug is listed on one of our Medical Drug Lists (MDLs), submit coverage authorization requests, reconsiderations and appeals to the Pharmacy Department through one of the methods listed above.
If the drug isn’t listed on one of our MDLs, submit drug coverage authorization requests, reconsiderations and appeals 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
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 new 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.
Our MDLs are replacing our comprehensive Medical Benefit Drug List (MBDL), which will remain active on this page through September 30. Effective October 1, the MBDL will retire and will no longer be accessible. If you have comments or feedback on how we can improve the MDL user experience, 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.