Step Therapy Programs for Members on the 2026 Drug List for Metallic Plans
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Defines step therapy pairings and program applicability for members on the 2026 Drug List for Metallic Plans (Marketplace) for individuals and small employer groups; affects prescribing providers and prior authorization staff administering prescription benefits.
No material clinical or coverage changes in this revision.
Step Therapy and Coverage Rules
Step therapy pairings by therapeutic category
Step therapy pairings listed; coverage of a step 2 agent may require prior trial of the corresponding step 1 agent unless an exception is granted.
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This step therapy policy applies to the drug categories and pairings shown on the 2026 Drug List for Metallic Plans covering individuals and small employer groups. These programs are subject to change and additional drugs may be added to the listed categories. If a requested drug is not on the Drug List, the member or the prescribing provider may request an exception review; as part of that review, the member may be required to meet the drug's step therapy program criteria before the exception is approved. To initiate an exception review, call the number on the member's ID card or have the prescribing provider follow the provider instructions referenced.
Provider Responsibilities, Prior Authorization, and Exceptions
Step therapy requirement and exception process
Step therapy is applied to specific drug categories on the 2026 Drug List; members must generally try the listed step 1 agent(s) before coverage of the corresponding step 2 agent(s). If the step requirement is not met, the provider or member may request an exception review or prior authorization as described in the policy.
- Members generally must trial the listed step 1 agent(s) prior to coverage of step 2 agents.
- Exceptions or prior authorization reviews can be requested when criteria are not met.
Listed step therapy pairings (examples by category)
The policy lists specific step 1 and step 2 preferred agents by therapeutic category (examples include: Atopic Dermatitis — Step 1: Elidel/pimecrolimus; Step 2: tacrolimus; Atypical Antipsychotics — multiple 1 vs 2 mappings such as Step 1: Abilify/Clozaril; Step 2: Risperdal/Risperidone ODT; Depression — multiple 1 vs 2 mappings including Auvelity/Bupropion ER 450 mg as Step 1 and agents such as Lexapro/Paxil as Step 2).
- Atopic Dermatitis — 1 = Elidel (pimecrolimus); 2 = tacrolimus. [chunk 0]
- Atypical Antipsychotics — multiple pairings (examples: 1 = Abilify, Clozaril; 2 = Risperdal, Risperidone ODT). [chunk 0]
- Depression — multiple pairings (examples: 1 = Auvelity, Bupropion ER 450 mg, Celexa; 2 = Lexapro, Paxil, Paxil CR). [chunks 0–1]
- Gabapentin ER — examples list Step 1 agents (Forfivo XL/Fluoxetine 60 mg/Gralise) and Step 2 agents (Wellbutrin SR, Zoloft, Horizant). [chunk 1]
- Insomnia — Step 1 examples include Ambien/Ambien CR/Belsomra; Step 2 examples include Lunesta, Quviviq, Rozerem. [chunk 1]
- PPIs — multiple PPIs are listed across step 1 and step 2 groups (examples: Aciphex, Dexilant, Nexium vs Prevacid Solutab, Prilosec). [chunk 1]
Exception request and contact
To request an exception review or start the prior authorization process, the member or prescribing provider should call the phone number on the member's ID card or have the provider follow the instructions on bcbsmt.com/provider.
- Call the number on the Member ID card to start an exception review.
- Providers may initiate requests via bcbsmt.com/provider as instructed in the policy.
Denial risk if step therapy not met
Prior authorization or an exception review may be denied if the drug-specific step therapy program criteria are not met for the requested medication.
- Approval of an exception may require that the member meet the drug's step therapy program criteria as part of the review.
- If criteria are unmet and no approved exception exists, the request may be denied.
Key Terms
Context and Policy Background
Step therapy is a utilization management program that requires trial of specified first‑line (step 1) agents before coverage of alternative (step 2) agents is approved. The document lists multiple therapeutic categories as examples where step therapy may apply — including, but not limited to, antidepressants, atypical antipsychotics, proton pump inhibitors, insomnia agents, gabapentin extended‑release formulations, phosphate binders, ophthalmic prostaglandins, and topical agents for atopic dermatitis. These examples illustrate the rationale for step therapy: to promote use of preferred initial therapies and require trial of those agents prior to approval of higher‑line alternatives, while retaining an exception process when clinically appropriate.
Step 1 (Initial) Agents
Step 1 (initial) agents — examples of preferred agents listed by category
Examples of step 1 preferred agents listed by category
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Operational Step Therapy Table
| Therapeutic category | Step 1 (preferred initial agents) | Step 2 (agents requiring prior trial of Step 1) |
|---|---|---|
| Atopic Dermatitis | Elidel (pimecrolimus) | tacrolimus |
| Atypical Antipsychotics (examples) | Abilify; Clozaril; Fanapt; Geodon; Invega; Latuda; (Eucrisa appears in text) | Risperdal; Risperidone ODT; Saphris; Secuado; Seroquel; Seroquel XR; Versacloz; Zyprexa (variants) |
| Depression (multiple pairings) | Auvelity; Bupropion ER 450 mg; Celexa; Citalopram; Cymbalta / Desvenlafaxine ER; Drizalma Sprinkle; Effexor / Effexor XR; Escitalopram; Exxua; Fetzima; Fluoxetine 60 mg | Lexapro; Paxil; Paxil CR; Pexeva; Pristiq; Prozac; Remeron; Sertraline; Trintellix; Venlafaxine ER; Viibryd; Wellbutrin SR (listed across pairings) |
| Gabapentin ER | Fluoxetine 60 mg; Fluoxetine delayed release; Forfivo XL; Gralise (gabapentin) | Wellbutrin SR; Zoloft; Horizant |
| Insomnia | Ambien; Ambien CR; Belsomra; Dayvigo | Lunesta; Quviviq; Rozerem; Silenor; Zolpidem (listed in Step 2 groupings) |
| Proton Pump Inhibitors (PPIs) | Aciphex; Aciphex Sprinkle; Dexilant (dexlansoprazole); Nexium; Prevacid; (other PPIs listed) | Prevacid Solutab; Prilosec; Protonix; Rabeprazole (sprinkle); Voquezna |
| Phosphate binders | Auryxia (ferric citrate); Fosrenol (lanthanum carbonate); (Aciphex appears in same list) | Renagel; Renvela; Velphoro; Prevacid Solutab (appears in Step 2 list) |
| Ophthalmic prostaglandins / former glaucoma agents | Iyuzeh; Lumigan; Lumigan Omlonti | Xalatan; Xelpros; Vyzulta; Xelpros Zioptan |
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