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Priority Partners Pharmacy & Formulary

Priority Partners wants our providers to view the list of Priority Partners Formulary Alternatives.

The Priority Partners formulary is a guide for health care providers and plan members to show which medications are covered by the plan, as well as any requirements such as Prior Authorization (PA), Step Therapy (ST), and Managed Drug Limitation (MDL). The Priority Partners formulary is a closed formulary, meaning only the drugs listed are covered. There may be occasions when an unlisted drug is desired for medical management of a patient. In those instances, the unlisted medication may be requested through the Non-Formulary authorization request process, described in the formulary booklet.

2016 Pharmacy Formulary

Please note: The Maryland Department of Health and Mental Hygiene is responsible for formulary management of drugs used for substance use disorder (SUD), AIDS/HIV, and most drugs used for behavioral health. Please refer to the Maryland Medicaid Mental Health Formulary and the Maryland DHMH Clinical Criteria for Substance Use Disorders (SUD) Medications for more specific information. This list may also be viewed at www.mdmahealthchoicerx.com.

For medications requiring Prior-Authorization, Managed Drug Limitations (MDL), and Step Therapy (ST), please refer to the lists in the formulary.

For medications requiring  Prior-Authorizations
For medications with Managed Drug Limitations (MDL)
For medications requiring  Step Therapy (ST)

Please note that in the event the Priority Partners precertification unit is closed, or a pharmacist cannot contact the prescribing physician, the pharmacist may dispense up to a 96-hour supply of the requested medication to an eligible Priority Partners member.

We will no longer be printing the formulary booklets. You may view the formulary here. Please call (888) 819-1043, option 4 to request further information. The formulary is updated on a regular basis, including when a new generic or brand-name medication becomes available and as discontinued drugs are removed from the marketplace The PPMCO formulary is subject to change at any time. Formulary updates will be provided quarterly, as needed and the changes can be found here.

Healthcare Common Procedure Coding System (HCPCS) J Codes

Certain medical injectable medications require prior authorization. To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select diagnoses will be exempt from the prior authorization requirement. Please refer to the specific drug policies to view select exempt diagnoses.

To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select ICD-9 diagnoses will be exempt from the prior authorization requirement. These diagnoses are listed below.

 

CodeExempt Diagnoses
J9035 (Avastin)Antineoplastic Chemotherapy 153.xx MALIGNANT NEOPLASM OF COLON
154.1x MALIGNANT NEOPLASM OF RECTUM
154.8x MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
162.xx MALIGNANT NEOPLASM OF TRACHEA BRONCHUS AND LUNG
189.xx MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
191.xx MALIGNANT NEOPLASM OF BRAIN
183.xx NEOPLASM OF OVARY
174.xx; 175.xx MALIGNANT NEOPLASM OF BREAST Opthalmic Therapy 362.5x EXUDATIVE SENILE MACULAR DEGENERATION, CYSTOID MASCULAR DEGENERATION
362.07x DIABETIC MACULAR EDEMA
362.2X RETINOPATHY OF PREMATURITY
362.83 RETINAL EDEMA
362.3X RETINAL VASCULAR OCCLUSION
J1745 (Remicade)555.xx REGIONAL ENTERITIS
556.xx ULCERATIVE ENTEROCOLITIS
569.xx OTHER DISORDERS OF INTESTINE
619.1x DIGESTIVE-GENITAL TRACT FISTULA FEMALE
696.0x PSORIATIC ARTHROPATHY
696.1x OTHER PSORIASIS AND SIMILAR DISORDERS
714.0x RHEUMATOID ARTHRITIS
714.1x FELTY'S SYNDROME
714.2x OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
720.0x ANKYLOSING SPONDYLITIS
J9310 (Rituxan)200.xx LYMPHOSARCOMA AND RETICULOSARCOMA AND OTHER SPECIFIED MALIGNANT TUMORS OF LYMPHATIC TISSUE
202.0x NODULAR LYMPHOMA
202.4x LEUKEMIC RETICULOENDOTHELIOSIS
202.8x OTHER MALIGNANT LYMPHOMAS
202.9x OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE
204.1x CHRONIC LYMPHOID LEUKEMIA
446.00 POLYARTERITIS NODOSA
446.4x WEGENER'S GRANULOMATOSIS
714.00 RHEUMATOID ARTHRITIS

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