Prior Authorization and Step Therapy

Prior Authorization is a tool that helps decide whether or not a prescription is covered before it is filled. The approval or denial is based on the plan design and focuses on safety and proper medication use. If a drug on the Mount Carmel MediGold requires prior authorization, you will see the abbreviation "PA" in the formulary. 

Beginning Jan. 1, 2025, some drugs on the Mount Carmel MediGold formulary will require Step Therapy, a form of prior authorization that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B. Drugs that require step therapy are marked with an "ST" in the formulary. 

You may also see drugs in the formulary marked with "B/D". This means that the drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 

Please have your pharmacist or doctor call CVS Caremark’s Prior Authorization department at 1-800-294-5979 (TTY 711) before prescribing or administering drugs that require prior authorization or step therapy. 

2024 Prior Authorization Criteria (last updated 11/01/2024)

2025 Prior Authorization Criteria (last updated 10/09/2024)

2025 Step Therapy (last updated 10/15/2024)