Prior Authorization & Step Therapy Policy
The goal of our prescription drug program is always to provide our members with safe, affordable medications. To help meet this goal, we rely on the help of our providers to comply with our administrative safeguards that are designed to keep costs down for members and give them the safest medications available. Two of these administrative tools are our Prior Authorization (PA) policy and our Step Therapy (ST) policy.
Prior Authorization requires you as a provider to request pre-approval to prescribe certain specialty and high-dollar prescription medications. When filing paperwork for Prior Authorization, your office must state the patient’s medical necessity that falls in line with Paramount’s PA criteria. Our PA program aims targets the use of new, costly, or potentially toxic medications that may be replaced by less expensive and safer alternatives.
When appropriate, we encourage our providers to implement Step Therapy (ST) programs wherein drug therapy begins with the most cost-effective and safest known medications. Our ST policies 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. This way, harmful side effects and risks are reduced, and risky or costly medications are prescribed only when Step 1 drugs are not effective. For ST purposes, a therapeutic “trial” of a medication is defined as a paid claim generated through our PBM by a participating pharmacy within the previous 120 days.
To learn more about our Prior Authorization and Step Therapy policy, please take a few moments to go over these documents:
For Commercial, Marketplace & Medicaid Drug Benefits
- Specialty Drug Prior Authorization Criteria
- Non-specialty Drug Prior Authorization and Step Therapy Forms
- List of Drugs Requiring PA (Advantage/Medicaid only)