Drugs covered under the medical benefit

Authorization requirements

Medical Benefit Drug List (MBDL)

Site of Service Policy

  • Site of Service may apply to: HMO/POS/PPO, Priority Health Choice (Healthy Michigan Plan and Medicaid) and individual plans.
  • Drugs in Appendix A of the policy may be covered in the home, a hospital outpatient infusion center, or an alternative Priority Health-approved site of service for Medicaid/Healthy Michigan members.
  • MBDL will also show which plan(s) Site of Service applies to

Max allowed unit edit for injectables

Priority Health applies a maximum allowed unit edit per dose, or per day where applicable, to units associated with certain injectable drug HCPCS Level I and II codes.

This applies to all plans: HMO/POS/PPO, Medicare, Priority Health Choice (Healthy Michigan Plan and Medicaid) and individual plans.

Priority Health has reviewed the maximum drug dosage recommended by the FDA or medically accepted indications for these drugs to determine criteria for processing these claims. Dosage units that exceed Priority Health criteria will be denied for medically unlikely or daily frequency exceeded.

If you feel the dosage amount or frequency is medically indicated, you can appeal for the denied unit amount.

Billing guidelines

  • Include the date span: If doses are given over several days, include the date span of when the doses were administered, so as not to exceed the maximum units per dose or day.
  • Observe minimum frequency: There are also some codes that have minimum frequency limitations (i.e. Prolia given every 6 months, Reclast given yearly), which may be impacted by these edits. Reasonable allowances for early scheduling have been provided.
  • Medical records may be requested for review of dosage reported on claim.