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 Saint Alphonsus Health Plan formulary requires prior authorization, you will see the abbreviation "PA" in the formulary. 

Some drugs on the Saint Alphonsus Health Plan 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. 

2026 Prior Authorization Criteria (last updated 12/31/2025)
2026 Step Therapy Criteria (last updated 12/31/2025)

Attention Providers: PA Forms Have Moved

Prior Authorization forms for Medicare Part D drugs can now be accessed in Section 7: Medicare Covered Drugs of the Provider Administrative Manual. 

Go to Provider Administrative Manual