Step Therapy Programs for Members on the Basic Drug List or Enhanced Drug List
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Defines step therapy groupings and preferred first- and second-line drugs for members on the payer's Basic Drug List or Enhanced Drug List; affects providers requesting coverage or prior authorization for drugs on those lists.
No material clinical or coverage changes in this revision.
Coverage and Step Therapy Requirements
Step Therapy Coverage Logic
Covered when members have met step therapy requirements according to the Basic or Enhanced Drug List groupings
Document lists first- and second-line agents by category; plan may require trial of step 1 prior to step 2. Some categories (e.g., Infertility) may not apply to all plans.
This step therapy program does not apply to all plans. Some plan-specific exceptions exist and certain benefit categories — for example, Infertility — may be exempt depending on the member's specific plan. For questions about whether the step therapy requirements apply to a particular member or category, contact the number shown on the member's ID card.
Provider Responsibilities and Step Assignments
Step therapy requirement for listed drugs
Drugs included in the step therapy program are organized into first-line ("1 =") and second-line ("2 =") preferred agents; coverage for a requested second-line agent may be contingent on prior trial of the listed first-line agent per the Basic or Enhanced Drug List.
- First-line agents are designated with "1 =" and are the preferred initial agents.
- Second-line agents are designated with "2 =" and may require prior trial/failure of a "1 =" agent before coverage.
Step assignments by therapeutic category
Therapeutic categories in the document pair each category with a '1 =' assignment (preferred initial agent[s]) and a '2 =' assignment (preferred subsequent agent[s]) to indicate required step order for that category.
- Examples include: Atopic Dermatitis — 1 = Elidel/pimecrolimus, Eucrisa; 2 = tacrolimus.
- Atypical Antipsychotics — 1 = Abilify; 2 = Risperdal.
- Many other categories (e.g., Depression, Colony Stimulating Factors, SGLT Inhibitors, Ophthalmic Prostaglandins) list specific 1 = and 2 = agents.
Contact for plan-specific questions
For plan- or member-specific coverage questions, contact the phone number shown on the member's ID card; plan-specific exceptions (for example, some infertility coverage) may apply.
- The document notes: "If you have any questions, call the number listed on your member ID card."
- It also states "**Does not apply to all plans," indicating some categories may be exempt depending on the plan.
Provider action summary — risk of denial or step requirement
Coverage may be denied or prior authorization required if a non-preferred (step 2) drug is requested without documentation that the member met the step therapy requirement (trial of the listed step 1 agent).
- The policy states coverage may be denied or require step completion if a non-preferred drug is requested without meeting step therapy requirements for the Basic or Enhanced Drug List categories.
- Providers should confirm member plan details via the member ID card number because exceptions exist.
First-line (Step 1) Therapy
Initial (Step 1) Therapy
First-line agents are designated with '1 =' in each therapeutic category; these are the preferred initial agents for step therapy.
Examples: Atopic Dermatitis 1 = Elidel (pimecrolimus), Eucrisa; Atypical Antipsychotics 1 = Abilify; Colony Stimulating Factors 1 = Opipza, Granix, Neupogen; Depression 1 = Nyvepria, Auvelity, Bupropion ER 450 mg; DPP-4 inhibitors 1 = Alogliptin and combinations; see full category listings in the document.
Step Therapy Implementation and Expectations
| Therapeutic category | Step 1 (1 =) — required initial agent(s) | Step 2 (2 =) — covered after trial/failure of step 1 | Coverage note |
|---|---|---|---|
| {"text":"Atopic Dermatitis","status":""},{"text":"Elidel (pimecrolimus); Eucrisa","status":""},{"text":"tacrolimus","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Atypical Antipsychotics","status":""},{"text":"Abilify","status":""},{"text":"Risperdal","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Colony Stimulating Factors","status":""},{"text":"Opipza; Fylnetra; Granix; Neupogen; Nypozi","status":""},{"text":"Zyprexa Zydis Releuko; Rolvedon; Stimufend; Udenyca; Ziextenzo; Nyvepria","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Depression","status":""},{"text":"Examples include Nyvepria; Auvelity; Bupropion ER 450 mg; Celexa; Citalopram; Cymbalta; Drizalma Sprinkle; Effexor/ Effexor XR; Escitalopram; Exxua; Fetzima; Fluoxetine formulations","status":""},{"text":"Examples include Udenyca; Ziextenzo; Lexapro; Paxil; Prozac; Remeron; Sertraline; Trintellix; Venlafaxine ER; Viibryd; Wellbutrin SR","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"DPP-4 Inhibitors and Combinations","status":""},{"text":"Alogliptin; Alogliptin‑metformin; Alogliptin‑pioglitazone; Jentadueto; Jentadueto XR; Kombiglyze XR","status":""},{"text":"Onglyza; Sitagliptin; Sitagliptin‑metformin; Sitagliptin‑metformin ER; Tradjenta; Zituvio","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Glucose Test Strips","status":""},{"text":"Non-preferred brand test strips and disks (listed as step 1 equivalents in document)","status":""},{"text":"Other non-preferred brand test strips and disks (listed as step 2 equivalents)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Infertility","status":""},{"text":"Gonal‑F; Chorionic Gonadotropin (listed under step 1 equivalents)","status":""},{"text":"Novarel (listed under step 2 equivalents)","status":""},{"text":"covered_with_criteria — note: does not apply to all plans"} | |||
| {"text":"Insomnia","status":""},{"text":"Ambien; Ambien CR; Belsomra; Dayvigo; Lunesta; Quviviq; Rozerem; Silenor (examples listed with step 1 equivalents)","status":""},{"text":"Other agents listed as step 2 equivalents (per category listings)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Kerendia","status":""},{"text":"Kerendia listed with certain step 1 groupings (document pairs Kerendia with step 1 equivalents)","status":""},{"text":"Rozerem; Silenor; Zolpidem (listed as step 2 equivalents in some groupings)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Ophthalmic Prostaglandins (formerly Glaucoma)","status":""},{"text":"Idose; Iyuzeh; Lumigan; Omlonti; Travatan Z (examples in step 1 groupings)","status":""},{"text":"Vyzulta; Xalatan; Xelpros; Zioptan (examples in step 2 groupings)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Oral Inhalers","status":""},{"text":"Advair Diskus; Alvesco; Fluticasone furoate ellipta (examples in step 1 groupings)","status":""},{"text":"Fluticasone propionate aerosol inhalation (examples in step 2 groupings)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"SGLT Inhibitors","status":""},{"text":"Brenzavvy (bexagliflozin); Inpefa; Invokana; Invokamet (examples listed under step 1 groupings)","status":""},{"text":"Invokamet XR; Qtern; Segluromet; Steglatro; Steglujan (listed under step 2 groupings)","status":""},{"text":"covered_with_criteria"} | |||
| {"text":"Topical NSAIDs","status":""},{"text":"Flector; Licart (listed under step 1 equivalents)","status":""},{"text":"Pennsaid (diclofenac 2% solution); Steglujan (listed under step 2 equivalents in document)","status":""},{"text":"covered_with_criteria"} |
Key Definitions
Policy Background
Background: This document is an administrative listing of step therapy equivalence groups that the payer uses to apply step requirements to drugs on the payer's Basic Drug List and Enhanced Drug List. Drugs are organized into therapeutic categories with designated first-line (noted as 1 =) and second-line (noted as 2 =) agents; members are generally expected to trial a listed step 1 (1 =) agent before coverage of a step 2 (2 =) agent in the same category. The listing is intended to support administrative prior authorization and coverage decisions and is not a clinical guideline. If there are questions about coverage or plan-specific exceptions, contact the number on the member ID card.
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