Search our Medical Drug Lists (MDLs) to understand coverage information by plan, including drug-specific utilization management rules like prior authorization requirements, step therapy requirements and/or age limits.
After you've reviewed coverage and criteria, learn how to submit a request for coverage.
How do we decide which drugs to cover on our MDLs?
We take a multi-faceted approach to safeguarding the safety and efficacy of the drugs/treatments we cover.
- Our Pharmacy & Therapeutics Committee carefully reviews drugs to determine whether they should be included on our formularies
- Each decision is guided by clinically-proven, evidence based standards to ensure medications/treatments are safe and effective
- We also incorporate a Drug utilization review program to support quality care and assure drugs and treatments are used appropriately and deliver the best possible outcomes for members
- For Medicare drug coverage determinations: Priority Health Medicare complies with NCDs, LCDs, LCAs and general coverage and benefit conditions included in Traditional Medicare law. This includes criteria for determining whether an item or service is a benefit available under Traditional Medicare. When such coverage and benefit criteria do not exist or are not fully established, Priority Health Medicare may create coverage criteria based on CMS-approved compendium and current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers. The coverage criteria are reviewed and approved by Priority Health’s Pharmacy and Therapeutics (P&T) Committed prior to implementation.
For more information, visit our formulary updates page.