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Code	Description	NDC	Brand Name Generic Name	Brand/ Generic/ Repackager	Dose/Strength	Status	Notes & Restrictions

Definition of Status

Icon	Status	Definition
	Non-Specialty	Drugs used to treat common, often chronic, conditions that affect a large population.
	Preferred Specialty	Brand-name and select specialty generic drugs that are used to treat difficult health conditions. These drugs are generally more cost-effective than non-preferred specialty products.
	Non-Preferred Specialty	Brand-name, specialty drugs that are used to treat difficult health conditions. Members pay more for non-preferred specialty drugs because there are more cost-effective generic or preferred drugs available.
	Cellular/Gene Therapy	Coverage is dependent on member's benefit plan documents. Cellular/Gene Therapy is defined by the FDA's Office of Therapeutic Products (OTP) as an approved Cellular and Gene Therapy product. For more information, see the FDA's website Cellular and Gene Therapy Products
	Preventive	May be covered as preventive at 100%. For further information, reference your plan documents and the Priority Health preventive health care guidelines.
	Refer to Approved Drug List (ADL)	Certain drugs are not covered under your medical benefit, but may be covered under your pharmacy benefit. Refer to the Employer group Approved Drug List and the MyPriority (Individual/Family) Approved Drug List for coverage under the Pharmacy Benefit.
	Not Separately Payable	Products that are not reimbursed individually but are considered part of the overall payment for a primary service or procedure.
	Refer to Contraceptive Coverage	Refer to Contraceptive: Physician supplied or administered contraceptive devices (diaphragms, IUD's, implantable devices, and injections) are covered under Women's Preventive Health (WPH) Care services. Refer to Priority Health's preventive health care guidelines for a complete list of services
	Covered	Products that are covered under the medical benefit
	Not Covered	This drug is not covered under your Medical benefit. For more information, call Customer Service using the phone number on the back of your ID card.

Definition of Restrictions

Icon	Restriction	Definition
	Age Limit	Coverage for this drug has age restrictions.
	Cellular/Gene Therapy	Cellular/Gene Therapy is defined by the FDA’s Office of Therapeutic Products (OTP) as an approved Cellular and Gene Therapy product. For more information, see the FDA’s website Cellular and Gene Therapy Products
	Coverage Changes	Coverage criteria for this drug are changing. View more info > Details section under Notes & Restrictions for upcoming drug‑specific details.
	Covered Alternatives	Drugs that are covered alternatives on the medical benefit. Search our Medical Drug List to understand the clinical requirements for the alternatives. Some drugs may require the provider to request authorization prior to the drug being administered.
	Drug Name	Indicates the brand name information available for drugs listed with “N/A” in the Drug Name field for HCPCS‑only drug results.
	For Ophthalmic use	Drugs/formulations intended for ophthalmic treatment.
	New To Market	Not covered until evaluated at P & T meeting (Pharmacy & Therapeutics Committee).
	No PA for Diagnosis	No Prior Authorization required when billed under the ICD-10(s) listed in the More Info > Details section under Notes & Restrictions
	Not Covered	This drug is not covered under your Medical benefit. For more information, call Customer Service using the phone number on the back of your ID card.
	Preferred Drug	This biosimilar or formulation is covered as the preferred drug. Other biosimilars or formulations may require step therapy, meaning you may need to try this product before others are approved.
	Preventive	May be covered as preventive at 100%. For further information, reference your plan documents and the Priority Health preventive health care guidelines.
	Prior Authorization	Priority Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Priority Health. If you don't get approval, Priority Health may not cover the drug.
	Quantity Limit	For certain drugs, Priority Health limits the amount of the drug that Priority Health will cover.
	Refer to Approved Drug List (ADL)	Certain drugs are not covered under your medical benefit, but may be covered under your pharmacy benefit. Refer to the Employer Group Approved Drug List and the MyPriority (Individual/Family) Approved Drug List for coverage under the Pharmacy Benefit.
	Site of Service	Priority Health requires that certain infusions or injections be administered in the home, an office, or another approved care setting. Refer to the Reimbursement Requirements For Outpatient Medical Drugs Billing Policy 092.