Some drugs have limitations on coverage

Some covered drugs may have additional requirements or limits on coverage before a Priority Health Medicare plan will pay for them. These requirements and limits may include:

• Prior authorization (PA): Priority Health Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Priority Health Medicare before you fill your prescriptions. If you don’t get approval, Priority Health Medicare may not cover the drug.
• Quantity limits (QL): For certain drugs, Priority Health Medicare limits the amount of the drug that Priority Health Medicare will cover. For example, Priority Health Medicare provides 18 tablets per prescription for Maxalt. This may be in addition to a standard one month or three month supply.
• Step therapy (ST): In some cases, Priority Health Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Priority Health Medicare may not cover drug B unless you try Drug A first. If Drug A does not work for you, Priority Health Medicare will then cover Drug B.
• Limited availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at toll-free 888 389-6648, 8:00 a.m. to 8:00 p.m., seven days a week. TTY/TDD users should call toll-free 888 551-6761.

To find each drug's specific limitations

On the main Priority Health website, you'll find an online tool called "Approved Drug List" that you can use to look up any drug to see if there are requirements that you try other drugs first, or get prior authorization, or any other coverage detail.
Go to the online Approved Drug List now. This link will open in a new window.

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Your doctor or other health care provider may need the following information.

Providers in our network have access to these forms on the priorityhealth.com website.

• Prior authorization forms for drugs
  Note: This link will open in a new window.
• Coverage Determination Request form (237KB PDF)