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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
	Part B Drug	Drugs you wouldn't usually give to yourself–like those you get at a doctor's office or in an infusion center. Examples of drugs covered under Part B can include, but are not limited to: drugs used with durable medical equipment, injectable and infused drugs, blood clotting factors, and some oncology drugs.
	Medicare Chemotherapy	Drugs used for oncology treatment. Some plans may have a lower cost share. Refer to plan documents for details.
	Part D Drug	This drug is not covered under the medical benefit. Refer to the Medicare Approved Drug List (ADL) 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	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.
	Not Covered by Medicare Billing	Certain medical billing codes are used to report specific drugs, services, and supplies. These types of codes may not be used to bill services paid under any Medicare payment system. Medicare does not provide reimbursement for services billed using these codes.
	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
	Additional coverage notes	Additional notes on drug coverage
	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
	CMS Coverage Determinations (LCD, NCD, LCA)	Priority Health Medicare complies with National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Article (LCA), and other coverage and benefit conditions included in Traditional Medicare law. When such coverage criteria do not exist or are not fully established, Priority Health Medicare may create coverage criteria based on CMS-approved compendium and current evidence in widely used treatment guidelines or clinical literature, which can be viewed at www.cms.gov/medicare-coverage-database/search.aspx.
	Coverage Change	Coverage criteria for this drug are changing. View more info > Details section under Notes & Restrictions for upcoming drug‑specific details.
	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.
	Multiple coverage tiers	Drug may be covered at a different tier depending on diagnosis
	New To Market	Drug has not been evaluated at P & T (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.
	Not Covered by Medicare Billing	Certain medical billing codes are used to report specific drugs, services, and supplies. These types of codes may not be used to bill services paid under any Medicare payment system. Medicare does not provide reimbursement for services billed using these codes.
	Not Separately Payable	Not separately payable under Part B
	Part B vs Part D	This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
	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%. See Comment for additional details.
	Prior Authorization	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.
	Step Therapy	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.