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Prior Authorization Criteria

At Paramount, our goal is always to provide the safest, most affordable, most efficient coverage possible for medical services. When we authorize coverage for certain drugs, equipment, or services, we want our providers to be confident that the covered treatments are the most appropriate and effective ones available. For your reference, we have provided our guidelines for selected coverage decisions.

Prior Authorizations

To make sure that services provided are readily available and are the most appropriate course of action, we require prior authorization for select outpatient procedures and durable medical equipment. Learn more about specific prior authorizations on our Medical Policy page. We have compiled a list of services that require a prior authorization, and have made it available to you.

Important - Please read our Prior Authorization process update.

We also require prior authorizations for specific self-injectable drugs. This step helps ensure that the drugs our providers prescribe are the most appropriate, cost-effective interventions for our members. Drug prior authorization is provided under either the medical or prescription drug benefit.

Additional Resources:

The medical policy information that we provide here is not a complete guide to coverage, and it is subject to change at any time. Different plans often have different coverage guidelines. For example, Medicare guidelines are used in the prior authorization of certain medical equipment, and Medicaid guidelines are used for Paramount Advantage members. When appropriate, you should discuss our medical policies with members and encourage them to learn what services and equipment are covered under their plan.

If you have any questions about our medical policy, please feel free to call us at 419-887-2520. Our fax numbers can be found here.