Prescriptions - Priority Partners MCO (2024)

If the Priority Partners precertification department is closed, or the pharmacist cannot contact the prescribing physician, the pharmacist may give up to a 96-hour supply of the medication to an eligible Priority Partners member.

Drugs that are not listed in the formulary must be approved by your plan before they can be filled at the pharmacy. Your doctor can request this drug by filling out a prior authorization request.

Your prescribing doctor will need to tell us the medical reason why your Priority Partners plan should authorize coverage of your prescription drug. Without the necessary information on the prior authorization form, we may not approve coverage of the drug. If the request is approved, you will be able to fill the prescription for this drug at the pharmacy. Medications that require prior authorization are listed in the formulary as “PA.”

Certain medications have a quantity limit, also known as managed drug limitations (MDL). These medications require prior authorization from your doctor for doses that are more than the recommended dosage. Medications with quantity limits are listed as “MDL” in the formulary. To obtain a larger quantity of these medications, your doctor should fill out a prior authorization request form and send it to Priority Partners. Priority Partners will then review the request and notify you and your doctor whether the request is approved or denied.

Some medications require you to try a preferred drug to treat your medical condition before we cover the drug your doctor may have initially prescribed. This is called step therapy, and the medications that require it are listed as “ST” in the formulary.

To request coverage for a drug that requires step therapy, you should have your doctor fill out a prior authorization request form and send to Priority Partners. Priority Partners will then review the request and notify you and your doctor whether the request is approved or denied.

To ensure safety and effectiveness of compounded medications, some compounded prescriptions may be rejected at the pharmacy and require prior authorization. Your doctor may complete the Compound Prior Authorization Form and fax to Priority Partners. The provider must also provide clinical documentation to support the request.

In addition to prescription benefits, some over-the-counter (OTC) medications are covered. Please refer to the Over-The-Counter Drug Coverage list in the pharmacy formulary. Please note that only certain OTC drugs listed in the formulary are covered by the plan. All other OTC medications are not covered.

Priority Partners encourages use of generic medications. Generic versions have the same active ingredients as their related brand-name drugs. Brand-name drugs with generic equivalents available are not included in the Priority Partners formulary. If you need a brand-name drug with a generic available, your doctor should send a completedprior authorization request to Priority Partners.

To determine your copay or find a lower-cost generic or preferred brand alternative for a medication, visit www.caremark.comand select “Check Drug Cost.”

Specialty medications are used to treat complex, long-term conditions. These are medications that may need special storage or have side effects that your doctor needs to monitor. Some of these medications are covered by your pharmacy benefits and some are covered by your medical benefits. Prior authorization may be required for most specialty medications. Specialty medications are available through specialty pharmacies, which can provide delivery services to your location of choice or your doctor’s. If you are unable to receive delivery of medication, the specialty medication may be obtained from a retail pharmacy. You may contact Priority Partners to request obtaining a specialty drug from a retail pharmacy.

Find a list of these medications and their authorization requirements on the Priority Partners formulary. Your doctor can request a prior authorization by filling out a prior authorization request and sending it to Priority Partners.

Specialty medications covered under your medical benefit are either given to you by your doctor or taken while your doctor is there with you. Some of these medical drugs may require prior authorization. Your doctor may ask Priority Partners to approve them.