Submitting a pharmacy benefit appeal
Choose from the plan options below.
For commercial fully funded group plans
For commercial fully funded group plans
If a pharmacy authorization request is denied, providers have two options depending on whether additional clinical information is available.
If additional clinical information is available
Submit the new information for review following the process outlined on our Pharmacy authorization requests page. Additional clinical information may support a different authorization outcome.
If no additional clinical information is available
If no new clinical information is available, you can submit an appeal following our appeal process for commercial fully funded group plans.
For commercial self-funded group plans
For commercial self-funded group plans
If a pharmacy authorization request is denied, providers have two options depending on whether additional clinical information is available.
If additional clinical information is available
Submit the new information for review following the process outlined on our Pharmacy authorization requests page. Additional clinical information may support a different authorization outcome.
If no additional clinical information is available
If no new clinical information is available, you can submit an appeal following our appeal process for commercial self-funded group plans.
For Federal employee health benefit plans
For Federal employee health benefit plans
If a pharmacy authorization request is denied, providers have two options depending on whether additional clinical information is available.
If additional clinical information is available
Submit the new information for review following the process outlined on our Pharmacy authorization requests page. Additional clinical information may support a different authorization outcome.
If no additional clinical information is available
If no new clinical information is available, you can submit an appeal following our appeal process for federal employee health benefit plans.
For Medicaid and Healthy Michigan plans
For Medicaid and Healthy Michigan plans
If a pharmacy authorization request is denied, providers have two options depending on whether additional clinical information is available.
If additional clinical information is available
Submit the new information for review following the process outlined on our Pharmacy authorization requests page. Additional clinical information may support a different authorization outcome.
If no additional clinical information is available
If no new clinical information is available, you can submit an appeal following our appeal process for Medicaid and Healthy Michigan plans.
For MyPriority plans
For MyPriority plans
If a pharmacy authorization request is denied, providers have two options depending on whether additional clinical information is available.
If additional clinical information is available
Submit the new information for review following the process outlined on our Pharmacy authorization requests page. Additional clinical information may support a different authorization outcome.
If no additional clinical information is available
If no new clinical information is available, you can submit an appeal following our appeal process for MyPriority plans.
For Medicare pharmacy plans
For Medicare pharmacy plans
- Fax: Send your completed fax forms to 877.974.4411
- Electronic prior authorization (ePA)
- Phone: Call 800.466.6642
- Mail to:
- Priority Health Appeals Coordinator - MS1260
1231 East Beltline Ave NE
Grand Rapids, MI 49525
- Priority Health Appeals Coordinator - MS1260
Appealing a pharmacy benefit claim
Pharmacy benefit claim appeals, including appeals for payment or network, are managed by Express Scripts, our Pharmacy Benefit Manager. Visit Express Scripts Pharmacist Resource Center (PRC) for more information.