Drugs covered by the medical benefit

Information for drugs billed as part of professional and institutional (CMS 1500, UB-04) claims. 

See related: 

Authorization requirements

Medical Benefit Drug List (MBDL)

Medicare

Medicaid 

MyPriority and Commercial

Medical Policy

Site of Service Policy

  • Site of Service may apply to: HMO/POS/PPO, Priority Health Choice, Inc. (Healthy Michigan Plan and Medicaid) and individual plans.
  • See Plan Document(s) and Medical Policy 91414 – Infusion Services & Equipment – Section I.C for details. The site of service policy applies to selected medications listed within the Medical Benefit Drug List (MBDL).

Max allowed unit edit for injectables

Priority Health applies a maximum allowed unit edit per dose, or per day where applicable, to units associated with certain injectable drug HCPCS Level I and II codes.

This applies to all plans: HMO/POS/PPO, Medicare, Priority Health Choice (Healthy Michigan Plan and Medicaid) and individual plans.

Priority Health has reviewed the maximum drug dosage recommended by the FDA or medically accepted indications for these drugs to determine criteria for processing these claims. Dosage units that exceed Priority Health criteria will be denied for medically unlikely or daily frequency exceeded.

If you feel the dosage amount or frequency is medically indicated, you can appeal for the denied unit amount.

Billing guidelines

  • Include the correct range: If a drug is given over several days, include the corresponding date range of when the doses were administered, so as not to exceed the maximum units per dose or day.
  • Observe minimum dosing intervals: There are some drugs that have minimum dosing interval limitations, which may be impacted by these edits (e.g., Prolia given every 6 months or Reclast given once yearly).
  • Medical records may be requested for review of dosage and/or dosing intervals reported on claims.
  • Units reported must correspond with the smallest dose (vial) available from drug manufacturer or pharmacy for purchase. This allows for minimal waste or discarded drug or biological. 

Medicaid carve-out drugs 

Some physician-administered drugs are excluded from coverage by Medicaid Health Plans but may be covered by the Michigan Fee-For-Service Medicaid plan. These are referred to as carve-out drugs. MDHHS maintains a list of these drugs: Medicaid Health Plan Carve-out (michigan.gov). Providers should contact the Fee-For-Service Medicaid program for coverage information and prior authorization.