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Our pharmacy network includes most chain retailers and independent pharmacies within the State of Maryland. Find a pharmacy in our network (registration is required for first-time users).
The pharmacy formulary is a list of drugs that are covered for Priority Partners patients. This list of drugs is created by doctors, nurses, and pharmacists who review how well the drug works, safety information, and comparisons to similar drugs. The formulary is updated regularly to include new drugs and the latest available safety information.
Effective Jan. 1, 2020, Priority Partners will begin covering prescription drugs for HIV/AIDS. The covered medications for HIV/AIDS are listed in the Pharmacy Formulary. This document lists all of the medications covered by Priority Partners. If you take any medications for HIV/AIDS, please speak to your doctor.
View information on a drug, including how to take the medication, possible side effects, and drug interactions.
Non-Formulary Emergency Supply
If the Priority Partners pre-certification 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 doctor before they can be filled at the pharmacy. Your doctor can request this drug by filling out a prior authorization request and sending it to Priority Partners. 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.”
Most opioids (also known as “narcotics” or “opiates”) require prior authorization. Your doctor must fill out an opioid prior authorization form. You may take this form to your doctor’s office to request an authorization for your medication.
To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications when rejected at the pharmacy, may require prior authorization. Ask your provider to complete the compound prior authorization form and fax to the number on the form for review. The provider must provide clinical documentation to support the request and demonstrate that an FDA approved commercially-available product is not clinically appropriate for the member.
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 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.
Over-the-Counter (OTC) Drug Coverage
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 completed prior authorization request to Priority Partners.
To determine your co-pay or find a lower-cost generic or preferred brand alternative for a medication, visit www.caremark.com and 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.
Specialty medications covered by your pharmacy benefit are available at a local pharmacy. You take these medications on your own. For some of them, your doctor may have to ask Priority Partners to approve them.
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 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 and your doctor may ask Priority Partners to approve them.
If you have other questions about our pharmacy benefits, please contact Customer Service toll-free at 1-800-654-9728.
All documents are available in paper form without charge. To request a paper copy, please call Customer Service at 1-800-654-9728 (TTY for the hearing impaired: 1-888-232-0488).