Nevada Step Therapy Protocol Exception Process
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Defines the process and clinical considerations for requesting an exception to step therapy requirements for members covered by Nevada fully insured plans or Nevada self-insured non-ERISA plans; applies to providers submitting prior authorization requests to CVS Caremark on behalf of Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Step Therapy Exception
As part of the review for a Step Therapy exception request, medical necessity requirements may still apply and are evaluated separately from step therapy exception criteria. Documentation submitted for an exception will be reviewed by CVS Caremark to determine whether both the step therapy exception criteria and any applicable medical necessity rules are met.
Provider Actions and Submission Requirements
Step‑therapy exception requires CVS Caremark PA form
Providers must submit the applicable CVS Caremark prior authorization (PA) form to request an exception to Step Therapy for Nevada-covered members. For oncology medications use the Nevada Cancer Step Therapy Exception/Prior Authorization Request Form; for all other medications use the Medical Exception / Prior Authorization / Precertification Request for Prescription Medications form. The provider may contact the CVS Caremark Prior Authorization Department or access the forms via the links provided in the policy.
- Oncology: Nevada Cancer Step Therapy Exception/Prior Authorization Request Form
- All other medications: Medical Exception / Prior Authorization / Precertification Request for Prescription Medications
Step Therapy overview and review
Step Therapy is a utilization management requirement that may apply to medications on the formulary; a provider may request an exception and CVS Caremark will review submitted information to determine whether the request meets the exception requirements.
- Exception requests are evaluated by CVS Caremark as part of the prior authorization process.
- Medical necessity requirements may still apply and are reviewed separately.
Required documentation with PA form
Complete and submit the applicable CVS Caremark prior authorization form (Oncology or non‑Oncology) and include documentation supporting one or more exception criteria listed in the policy.
- Documentation must support one of: contraindication/adverse reaction to the alternate drug; expected ineffectiveness of the alternate; prior trial and discontinuation of the alternate (or same‑class drug) for lack of efficacy or adverse event; alternate not in patient’s best interest; or patient stability on the requested drug.
- Provider may contact CVS Caremark Prior Authorization Department for the appropriate form.
Denial triggers for step‑therapy exceptions
Requests that do not meet the exception criteria or that lack the required documentation may be denied during CVS Caremark's review.
- Failure to provide documentation supporting one of the listed exception criteria may result in denial.
- Not meeting any of the specified clinical considerations (contraindication, expected ineffectiveness, prior trial failure, not in patient’s best interest, or stability) is a basis for denial.
Step Therapy Operational Requirements
| Step | Requirement | Required documentation / notes |
|---|---|---|
| 1 | ||
| Provider must submit the applicable CVS Caremark prior authorization (PA) form to request an exception to Step Therapy. | ||
| Complete and submit the appropriate PA form (Oncology form for oncology medications; Medical Exception / Prior Authorization form for all other medications). |
Definitions
Background
Step therapy is a utilization management requirement that may require a patient to try a specified alternate medication before coverage of the requested drug is authorized. When a formulary drug is subject to Step Therapy, a provider may request an exception to bypass that requirement by completing and submitting the applicable CVS Caremark prior authorization form — separate forms exist for Oncology and all other medications. Exceptions are considered when clinical circumstances make the required alternate inappropriate, ineffective, or when the patient is already stable on the requested therapy; CVS Caremark reviews the submitted documentation against the exception criteria to determine coverage.
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