Drug and Specialty Drug Prior Authorization
Prior Authorization and 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 requesting a Prior Authorization (PA), your office must send in clinical documentation (office notes, lab results, medical literature, whichever is applicable) that includes, but is not limited to information regarding the patient’s diagnosis, the patient’s medical need for the medication, and any alternative medications that have been trialed.
Paramount also has Step Therapy (ST) policies in place that require that generic or therapeutic equivalents are tried prior to higher cost or newer drugs. If Step Therapy criteria are not met, a step therapy exception request can be submitted with supporting clinical documentation as stated above for prior authorizations.
To learn more about our Prior Authorization and Step Therapy policy, please take a few moments to go over the documents on this page.
For Medicare Benefits
- Drug Prior Authorization Criteria and Procedure Forms
Drug Prior Authorization and Procedure Forms
Commercial group benefits can have different prescription drug coverage criteria. A member can view their Summary of Benefits to determine which formulary they are on for their prescription drug coverage.
The most efficient method for submitting a prior authorization (PA) request is using the electronic prior authorization (ePA) portal, Cover My Meds. The request will be routed as appropriate to either CVS Caremark or Paramount based on the member's formulary. PA criteria is available in the Cover My Meds ePA portal. If you are unable to submit a PA request through the ePA portal, please see below for fax guidance.
All specialty medications for Commercial employer-group members are reviewed by CVS Caremark. If unable to submit an ePA, please fax all specialty pharmacy PA requests to 866-249-6155. If you have any questions or would like criteria sent to you, please call CVS Caremark at 866-814-5506.
Specialty medications for Marketplace and ACA Alliance members are reviewed by Paramount. If unable to submit an ePA, please fax a request to 844-256-2025.
PA requests are reviewed by either Paramount or CVS Caremark depending on the formulary.
Requests for non-specialty medications for Commercial and Marketplace members are reviewed by Paramount. If unable to submit an ePA through Cover My Meds, please fax a request to 844-256-2025. Full criteria is available in the ePA portal or by request at 800-891-2520 Option 2.