Prior Authorization and Step Therapy Policy
When it comes to making sure you are prescribed the safest, most cost-effective medications, we at Paramount believe that it is good to have safeguards in place. That’s why we implement prior authorization and step therapy policies. These policies help ensure that medications are properly and safely prescribed to our members—all while saving money for employers and members.
Prior Authorization (PA)
Prior Authorization is an administrative tool that we use with certain specialty or high-cost prescription medications. With Prior Authorization, your health care provider must request pre-approval to prescribe certain drugs. Before a provider can write a prescription for a certain medication, they have to show us that there is a medical necessity for it. Medications that we target for Prior Authorization are usually new, costly, or potentially toxic medications that may be replaced by less expensive, safer alternatives. This helps keep you safe from potential side effects of unknown drugs.
Non-Specialty Drug Prior Authorization Forms
When a Prior Authorization is needed for a drug, Paramount will need the applicable Prior Authorization Form completed. Typically, the prescribing physician will complete and submit the form.
Specialty Prior Authorization Criteria
Please search the drug name or drug class in our Specialty PA Criteria Library to view the prior authorization criteria question set for a particular drug. Members of Paramount Advantage, Paramount Commercial, and Paramount Marketplace drug plans will follow these criteria, when applicable. The product lines that the criteria apply to are indicated at the top of each document.
Step Therapy (ST)
Step Therapy means that providers are encouraged to prescribe the most well-known, cost-effective drugs for you when you are first beginning drug therapy for a medical condition. Why begin treatment with a brand-new, costly, or potentially risky medication when there are drugs out there that are already known to be safe and inexpensive? Of course, if your provider decides that a more costly or less well-known drug is the best course of treatment, they still have the option of prescribing it to you. ST policies simply require that a generic or therapeutic equivalent (Step 1) of a high cost or highly toxic drug be tried before a Step 2 drug, and a Step 2 drug before a Step 3 drug.