The Medicaid Medical Drug List (MDL) shows which drugs require prior authorization or have clinical restrictions for non-emergency, outpatient claims billed to the medical benefit of Priority Health Choice, Inc. plans; Medicaid, Children's Special Health Care Services (CSHCS), and Healthy Michigan.
Providers should first check the applicable fee schedule to ensure the drug HCPCS or CPT code is present, and confirm the National Drug Code (NDC) is included in the Medicaid Drug Rebate Program. Drugs whose HCPCS and CPT code is included on the applicable fee schedule, but not listed here, do not have any clinical prior authorization requirements. All other billing and payment rules apply.
Most drugs intended for self-administration are only covered by the pharmacy benefit. Refer to Medicaid Approved Drug List (ADL) for pharmacy benefit coverage.
For Medicaid beneficiaries who are also eligible for Medicare, providers should refer to the Medicare plan for coverage information. For Medicaid beneficiaries with other insurance, providers should refer to that plan for coverage information. Per Medicaid policy, the rules of the primary plan must be followed.
Drug is excluded from coverage per plan documents.
This drug is not covered.
Carve Out drugs are excluded from coverage under the medical benefit of this plan. The drug may be covered by Fee For Service (FFS) Medicaid. Providers may use CHAMPS to review FFS coverage.
This drug requires prior approval before it will be covered. Please see the Medicaid Medical Drug Criteria document for requirements.
Priority Health Billing Policy 092 Reimbursement Requirements for Outpatient Medical Drugs applies.