Drugs covered under the medical benefit

Authorization requirements

Medical Benefit Drug List (MBDL)

Medical Policy

Site of Service Policy

  • Site of Service may apply to: HMO/POS/PPO, Priority Health Choice (Healthy Michigan Plan and Medicaid) and individual plans.
  • See Plan Document(s) and Medical Policy 91414 – Infusion Services & Equipment – Section I.C for details. The site of service policy applies to selected medications listed within the Medical Benefit Drug List (MBDL).

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.

Medicaid forms