Currentalign_powered_by_sanford_health_planPolicy N/A

Step Therapy

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Defines Sanford Health Plan's step therapy program requiring trial and failure of specified lower-cost formulary medications before covering target medications; applies to providers requesting coverage for plan members. Non-formulary drugs are handled via formulary exception.

Policy Summary

Payeralign_powered_by_sanford_health_plan

PolicyStep Therapy — coverage criteria for formulary medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit step therapy override or formulary exception requests via the Sanford Provider Portal and include medical records documenting at least a 30-day trial and failure of required step medications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-dayminimum trial supply required before plan will cover target medication

formulary-onlypolicy pertains only to medications on the formulary

15/30dclaim quantity requirement mentioned for some CGRP agents

Atypical Antipsychotics

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Currentalign_powered_by_sanford_health_planPolicy N/A

Step Therapy

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Policy Summary

Payeralign_powered_by_sanford_health_plan

PolicyStep Therapy — coverage criteria for formulary medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-dayminimum trial supply required before plan will cover target medication

formulary-onlypolicy pertains only to medications on the formulary

15/30dclaim quantity requirement mentioned for some CGRP agents

Atypical Antipsychotics

therapeutic class governed

~20+distinct drug names referenced

Coverage and Step Therapy Criteria

Step therapy coverage requirement

Covered when ALL of the following are met

Step therapy prerequisite: Member medical records document trial and failure of at least a 30-day supply of one or more specified step medications prior to coverage of the target medication.30 days

Applies only to formulary medications; non-formulary requires formulary exception.

Step-based coverage criteria (implicit)

Coverage is organized by step levels; agents are listed as Step Medication or Target Medication with step numbers (1–3).

Step assignment: Medications are grouped into Step Medication or Target Medication and assigned step numbers 1 through 3; coverage of a higher-step/target medication requires meeting step requirements (trial/failure/contraindication) of prior step medications.step 1-3

Document lists many specific drugs under these labels but does not provide explicit logical tree in this excerpt.

Step Therapy Criteria (partial)

Covered when specific step therapy requirements are met (partial representation):

Step mapping: Target antipsychotic is subject to step therapy requiring prior trial(s) of listed step medications at the specified step level (1, 2, or 3) depending on the target drug.

Document is repetitive and partial; exact required prior agents per target/step not fully legible in this segment.

Step sequence coverage criteria

Covered when ALL of the following are met for a target medication:

Step therapy sequence: Patient has trialed and had inadequate response or intolerance to medications assigned to the lower numbered step(s) as listed in the step therapy table (steps 1→2→3).N/A

Document lists many antipsychotic agents repeatedly across steps; provider must show prior step failure before target coverage.

This step therapy policy applies only to medications that are included on the plan formulary. Medical records must document that the member has trialed and failed at least a 30-day supply of one or more listed step medications before the plan will cover the associated target medication. Requests for coverage of non‑formulary drugs are reviewed through a separate formulary exception process; to request a step therapy override or formulary exception submit the request via the Sanford Provider Portal at sanfordhealthplan.com.

The policy excerpt does not state any explicit exclusions beyond the formulary/non‑formulary distinction. The document separately identifies a distinct step therapy path for C. difficile (Dificid) within the listing, and otherwise lists numerous target and step medication groupings (for example, multiple atypical antipsychotics and their associated step medications) without providing additional exclusion language.

A separate step therapy pathway is called out for Clostridioides difficile (C. diff) treatment with Dificid; this indicates that C. diff therapies are managed on their own step sequence rather than within the general antipsychotic or other group listings.

Within the provided excerpt there are no other explicit exclusions stated. The step therapy lists repeatedly present target and step medications and step levels (1–3) but do not present exclusionary statements in these fragments.

Initial (Step 1) Therapy Requirements

inv-103: Initial (Step 1) therapy (implicit)

Covered when ALL of the following are met (partial excerpt):

CGRP step therapy requirement: Patient must have trialed at least one medication from two different preventive classes (examples: beta-blockers and tricyclic antidepressants; anti-epileptics and SNRIs are also listed) prior to coverage of CGRP-targeted prophylactic agents.at least 1 agent from 2 different classes

Examples include propranolol, timolol, metoprolol, amitriptyline, nortriptyline, divalproex, topiramate, venlafaxine, duloxetine.

CGRP claim quantity: For specified CGRP target medications (e.g., Aimovig, Emgality, Ajovy, Nurtec, Qulipta) the pharmacy claim must be for a quantity of 15 over a 30-day span.quantity = 15 per 30 days

Quantity requirement repeated in document fragments.

inv-104: CGRP initial therapy (partial)

Step Levels and Tables

Requirement	Details
Member must trial and fail one or more specified step medication(s)	Medical records must document trial and failure of at least a 30-day supply of the required step medication(s) prior to coverage of the target medication; applies to formulary medications (non‑formulary handled by formulary exception).
Failure documentation	Medical records demonstrating trial and failure of at least a 30‑day supply must be provided with prior authorization request.

Requirement	Details
Follow step sequencing	Prescribers must follow the step sequence (steps 1–3) as listed; requests for medications assigned to higher steps should include documentation of prior‑step trials, failures, or contraindications.
Documentation needed when skipping steps	Requests inconsistent with documented step relationships (e.g., skipping required step medications) should include evidence of failure or contraindication to prior step agents.

Step	Requirement
Step 2	Medications assigned to step 2 require documented trial and inadequate response or intolerance to step 1 agents before approval of step 2/target medications.

Step	Requirement
Step 3	Medications assigned to step 3 require documented failure or intolerance of step 2 agents (and prior lower steps as indicated) before target coverage.

Target medication	Prescriber must trial
Various target medications (e.g., antipsychotics, COPD inhalers, GI agents)	Prescriber must trial the specific step medication(s) listed for the target medication (document prior trials and failures per the step table).

Target medication	Step 2 step agents
Veozah (example target)	Paroxetine 7.5 mg; gabapentin; SSRIs/SNRIs as listed (citalopram, escitalopram, sertraline, desvenlafaxine ER, duloxetine)

Target medication	Step 3 step agents
Pulmicort HFA (example target)	Inhaled corticosteroid alternatives listed (Arnuity Ellipta, Asmanex, Flovent Diskus) per step table; higher‑step agents require prior trials of listed inhaled corticosteroids.

Requirement	Details
Document prior trials	Must document prior trials of lower‑step medications (medication names and step level) before authorization of the target medication.
Evidence to submit	Medical records or pharmacy claims documenting trials and failures of required step medications should be submitted with the prior authorization request.

Condition	Requirement
General (step progression)	Documented inadequate response or intolerance to step 1 agents is required before progressing to step 2 or target medications.

Condition	Requirement
General (step progression)	Documented inadequate response or intolerance to step 2 agents is required before progressing to step 3 or target medications.

CGRP requirement	Details
Prior trials from two classes required	Before CGRP prophylactic agents (e.g., Aimovig, Emgality, Ajovy, Nurtec, Qulipta) are approved, patient must trial at least one medication from two different classes (examples: beta‑blockers, tricyclic antidepressants, anti‑epileptics, SNRIs).
Quantity limit for some CGRP agents	For several CGRP agents the pharmacy claim must be for a quantity of 15 over a 30‑day span.

Step level	Antipsychotic agents (example)
Steps 1–3	Atypical antipsychotics (e.g., Vraylar, Fanapt, Latuda, Rexulti, Saphris, Caplyta, Secuado, Lybalvi, aripiprazole, clozapine, olanzapine, paliperidone ER, quetiapine, risperidone, ziprasidone) are listed under step headings; specific step assignments and required trials are presented in the table.

Requirement	Constraint
Prior trials and quantity limits	Prior trials of the specified step medications must be documented; for certain agents (notably some CGRP products) claims must meet quantity limits (commonly 15 per 30 days).

Enforcement	Details
Prior failure required	Approval of listed target medications requires prior failure of the specified step medication(s); several entries explicitly require failure of two prior step medications for certain conditions (e.g., chronic idiopathic constipation).

Step level enumeration	Requirement
Steps 1–3 enumerated	Prior trials of the listed step medications for steps 1–3 must be completed and documented for the associated target medications as shown in the step tables.

Documentation requirement	Details
Proof of prior trials required	Documentation must support prior trials and failures (or intolerance) of the required step medications; medical records demonstrating trial and failure of at least a 30‑day supply are required with prior authorization.

Target medication (examples)	Mapped step medications
Qbrexza	Drysol; Xarac AC (hyperhidrosis step medications listed prior to Qbrexza)
Pulmicort HFA	Arnuity Ellipta; Asmanex; Flovent Diskus (inhaled corticosteroid step alternatives listed)

General mapping	Requirement
Prior trials indicated	Prior trial(s) of listed step medications are indicated before coverage of associated target medications across multiple therapeutic areas (COPD, fibromyalgia, GI, etc.).

Example target → step	Required prior trials
Qbrexza → Drysol / Xarac AC	Documented trial of Drysol or Xarac AC required prior to Qbrexza (hyperhidrosis mapping in table).
Pulmicort HFA → Arnuity Ellipta / Asmanex / Flovent Diskus	Listed inhaled corticosteroids are presented as step medications prior to some target inhaled agents; prior trials should be documented.

Target med category	Step medications required
Non‑hormonal VMS (example: Veozah)	Trial of listed agents such as gabapentin or an SSRI/SNRI (citalopram, escitalopram, paroxetine ER, sertraline, desvenlafaxine ER, duloxetine, fluoxetine, fluvoxamine, venlafaxine) is required before coverage of Veozah.

General rule	Provider action
Prior trials required	Prior trials of specified step medications are required before coverage of target medications; documented evidence must be submitted with the prior authorization request.
Submission requirement	Prescribers must include documentation of prior step medication trials and failures when requesting prior authorization or a step override via the provider portal.

Prior Authorization, Documentation, and Denial Triggers

Note

Submit override/exception via Sanford Provider Portal

To request a step therapy override or formulary exception, log into the Sanford Provider Portal at sanfordhealthplan.com.

Contact pharmacy management for questions: (800) 752-5863.

Prior Authorization

Prior authorization implied if antipsychotic step requirements not met

When prescribing an atypical antipsychotic without documented completion of the listed prior step(s, prior authorization is implied and the provider must document step trials or an exception.

Provide medical record evidence of prior step medication trials and failures or documented contraindication/intolerance.

Prior Authorization

Documentation Requirements and Denial Triggers

Note

Quantity Limits and Key Values

Minimum trial duration — 30 days

Minimum trial durationMember medical records must document trial and failure of at least a 30-day supply of one or more step medications before the plan will cover the target medication.

Applies to formulary medications onlyThis policy pertains only to medications on the formulary; non-formulary medications will be reviewed as a formulary exception.

How to request overrideTo request a step therapy override or formulary exception, log into the Sanford Provider Portal at sanfordhealthplan.com.

CGRP claim quantity — 15 over a 30-day span

CGRP claim quantity requirementClaims for certain CGRP agents must be for a quantity of 15 over a 30-day span.

Affected agents (examples)Aimovig, Emgality, Ajovy, Nurtec, Qulipta are listed with the quantity=15 requirement.

Background and Definitions

Step therapy is a utilization management strategy that requires that a member trial and fail lower‑cost, therapeutically equivalent step medications before the plan will cover a higher‑cost target medication. Per the policy text, medical records must document that the member has tried and failed at least a 30‑day supply of one or more step medications prior to coverage of the target medication.

Step medication — definition

Definition: Step medicationA lower-cost formulary medication that must be tried and failed before coverage of the target medication is approved.

RoleUsed as the required initial therapy in the plan's step therapy program; documentation of trial/failure (typically 30 days) is required.

ApplicabilityApplies only to formulary medications; non-formulary alternatives require a formulary exception request.

Target medication — definition

Definition: Target medication

Quantity Limits for Specific Agents

Aimovig, Emgality, Ajovy, Nurtec, Qulipta — quantity 15

Quantity limit (repeat)Aimovig, Emgality, Ajovy, Nurtec, Qulipta — quantity limit 15 per 30 days (reiterated across CGRP entries).

Applies to pharmacy claimsPharmacy claims for these agents must meet the quantity specification or may be denied.

Associated prior-step requirementThese agents are also subject to step therapy requiring trials of one medication from two different classes prior to approval.

CGRP agents list — Aimovig / Emgality / Ajovy / Nurtec / Qulipta entries reference quantity 15

CGRP agents listAimovig / Emgality / Ajovy / Nurtec / Qulipta — entries reference a quantity of 15 over a 30-day span.

Step therapy noteMust try one medication from two different classes (beta-blockers, tricyclics, anti-epileptics, SNRIs) before CGRP agents are approved.

Policy Summary

Payeralign_powered_by_sanford_health_plan

PolicyStep Therapy — coverage criteria for formulary medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Initial step requirements for CGRP prophylactics (partial):

CGRP initial step requirement: Must try at least one medication from two different classes (beta-blockers; tricyclic antidepressants; anti-epileptics; SNRIs) prior to coverage of CGRP prophylactic target medications.1 agent from 2 classes

Specific agent examples listed in source (propranolol, amitriptyline, timolol, nortriptyline, metoprolol, atenolol, nadolol, divalproex, topiramate, venlafaxine, duloxetine).

inv-105: Initial therapy (migraine) - partial

Initial step therapy requirements (partial/fragments):

Migraine initial steps: Trial of at least one medication from two different classes (examples: beta-blockers such as propranolol, timolol, metoprolol; tricyclics such as amitriptyline, nortriptyline; anti-epileptics such as topiramate, divalproex; SNRIs such as venlafaxine, duloxetine) is required prior to some migraine target biologics.

inv-106: Initial therapy (chronic idiopathic constipation) - partial

Initial step therapy requirements for chronic idiopathic constipation agents (partial):

Constipation prior steps: Patient must have failed two step medications before approval of target chronic idiopathic constipation agents.fail two step medications

Examples of step medications include Amitiza, Linzess, Lubiprostone, Motegrity, Trulance, Ibsrela as listed in the source.

inv-107: Initial therapy for chronic idiopathic constipation agents — Initial coverage for target GI agents requires prior failures

Initial coverage for target GI agents requires prior failures:

GI agent prior failure: Patient must have documented failure of plan-specified prior step medications before coverage of target GI agents; chronic idiopathic constipation listings repeatedly state the patient 'must fail two-step medications.'fail two prior step medications

Phrase 'must fail two-step medications' appears repeatedly for constipation agents.

inv-108: Initial therapy requirements

Initial therapy prerequisites

Two-step failure before target agent: Member must have failed two prior step medications as listed for the condition before initiation of the target medication.2 failed step medications

Document repeatedly uses the phrase 'must fail two-step medications' to describe this requirement.

inv-109: Initial therapy (step requirements)

Initial therapy requirements as implied by step therapy lists:

Constipation step agents: Trials of listed constipation agents (Amitiza, Linzess, Lubiprostone, Ibsrela, Motegrity, Trulance) are required before target drugs; chronic idiopathic constipation specifically requires failure of two step medications.

inv-110: Initial step medication requirements (partial)

Examples of required initial (step) therapies before coverage of target medications as listed in this segment.

example sequences: Examples include: allopurinol required before Uloric (febuxostat); colchicine 0.6 mg tablet (Colcrys generic) required before colchicine capsule (Mitigare); Drysol/Xarac AC required prior to Qbrexza; Pulmicort HFA and other inhaled corticosteroids listed as step medications prior to some target inhaled agents.

These examples are presented in the step tables; durations/failure documentation also apply per policy.

inv-111: Initial step requirements (partial)

Partial list of initial/step therapy relationships present in this section

Qbrexza mapping: Qbrexza is listed with step medications Drysol and Xarac AC as required prior therapies; inhaled corticosteroid mappings (Pulmicort HFA → Arnuity Ellipta/Asmanex/Flovent/Qvar) are shown as step relationships in this fragment.

Partial/fragmented listing in source.

inv-112: Initial therapy — Initial step medications listed for non-hormonal VMS

Initial step medications listed for non-hormonal VMS

Initial step agents: Trial of gabapentin or an SSRI/SNRI (examples: citalopram, escitalopram, paroxetine ER, sertraline, desvenlafaxine ER, duloxetine, fluoxetine, fluvoxamine, venlafaxine) is required prior to coverage of some non-hormonal VMS target medications (e.g., Veozah).

inv-113: Initial therapy examples — Initial step requirements for certain target drugs (examples)

Initial step requirements for certain target drugs (examples):

Insomnia class initial step: Before Dayvigo, Belsomra, Quviviq are covered, patient must have trialed listed sedative-hypnotics: eszopiclone, zaleplon, zolpidem, triazolam, temazepam, ramelteon, doxepin.trial and failure of listed agents

From source chunk listing insomnia step medications.

Provide evidence of prior step trials for antipsychotic targets

Prior authorization is expected for target antipsychotic agents if the patient has not met the required step therapy trials; prescribers should submit evidence of prior step medication trials and failures.

Document which step level was completed (1, 2, or 3) and the specific medications tried.

Prior Authorization

Obtain prior authorization when step requirements unmet

Prior authorization is required when a target medication is subject to step therapy and the patient has not met the indicated prior step(s); the request must show failure or intolerance to the required step medications.

Include documentation of medication names, trial duration, and reason for discontinuation (failure or intolerance).

Prior Authorization

CGRP prior authorization: trials from listed classes and quantity compliance

For CGRP prophylactic target agents, prior authorization must include evidence of trials of step medications from the listed classes (e.g., beta-blockers, tricyclics, anti‑epileptics, SNRIs) and, for some CGRP agents, pharmacy claims must meet the quantity requirement of 15 over a 30-day span.

Document trials from at least two different classes as indicated.
Ensure pharmacy claim quantity equals 15 per 30 days for listed agents (Aimovig, Emgality, Ajovy, Nurtec, Qulipta).

Prior Authorization

Document trial and failure of specified step medications

Prior authorization for many target medications requires documentation that the patient trialed and failed the specified step medications; for Chronic Idiopathic Constipation agents this commonly requires failure of two prior step medications.

Include records showing trials and failures of the named step agents (examples: Amitiza, Linzess, lubiprostone, Motegrity, Trulance, Ibsrela).

Prior Authorization

Show failure of required prior step medications on PA

When requesting coverage for a target medication listed under step therapy, the prior authorization request must show failure of the required prior step medication(s) before the target medication will be approved.

If the policy lists a two‑step failure requirement, provide documentation showing two prior step medications were tried and failed.

Prior Authorization

Two‑step failure evidence required for certain targets

For target medications that specify 'must fail two‑step medications,' prior authorization requires evidence that the patient failed the two listed step medications prior to approving the target agent.

Supply clinical notes or pharmacy claims demonstrating trials and outcomes for both required step agents.

Prior Authorization

Demonstrate failure of listed step meds for CIC targets

Prior authorization for Chronic Idiopathic Constipation target medications requires demonstration of failure of the listed step medications (the policy repeatedly states 'must fail two‑step medications' for these agents).

Document trials of the named constipation step agents and show inadequate response or intolerance before approval of target agents.

Note

Medication lists present; explicit PA codes not included in excerpt

This excerpt lists many target and step medications (medication name mappings are provided) but does not include an explicit prior authorization form number or billing code in this fragment.

Use the Sanford Provider Portal prior authorization workflows (per policy) since no specific codes are listed here.

Note

Step-listing implies PA but no specific PA codes provided

The step therapy listings imply that prior authorization is required for the named target medications when step requirements are not met, but this segment does not present specific prior authorization form or codes.

Follow the plan's prior authorization process via the provider portal for requests tied to step therapy entries.

Prior Authorization

Document step trials for target medications (examples included)

Target medications identified in the step tables (examples: Qbrexza, Pulmicort HFA, Veozah) require documented trials of the listed step medications in the prior authorization request to be approved.

Include evidence of trial/failure or intolerance to the step medications named alongside each target drug.

Prior Authorization

PA requires documented trial and failure (or intolerance) of step meds

Prior authorization decisions are based on evidence of trial and failure (or intolerance) of the listed step medications; the PA should include documentation of those trials before a target medication is approved.

Provide dates, durations, and outcomes of step medication trials in the medical record or pharmacy claims.

Denial Risk

PA requires documented step failures; lack of documentation risks denial

Prescribers must document failure of required step medications when requesting prior authorization for target medications listed in the step therapy tables; failure to provide this documentation may result in denial.

Medical records must show trial and failure of at least a 30‑day supply of one or more step medications prior to PA submission.
If medications are non‑formulary, submit a formulary exception via the Sanford Provider Portal.

Documentation Required

Follow listed target→step medication mappings in PA requests

The document lists target medications with their associated required step medications (e.g., Qbrexza → Drysol/Xarac AC; Pulmicort HFA → inhaled corticosteroids), and prescribers must follow these mappings when preparing PA requests.

When requesting PA, reference the specific step medication(s) named for the target medication and include trial/failure details.

Step Therapy

Adhere to antipsychotic step sequencing or document exception

Step therapy groupings for many atypical antipsychotics are defined across step levels 1–3; prescribing outside the specified step order may require an exception and implied prior authorization.

Document contraindication or intolerance if skipping lower‑step agents; include which step level was completed in the PA request.

Documentation implicationPharmacy claims must document required prior medication trials and meet claim quantity specifications (e.g., quantity of 15 over 30 days).

Aimovig, Emgality, Ajovy, Nurtec, Qulipta — quantity limit 15

Quantity limitAimovig, Emgality, Ajovy, Nurtec, Qulipta — quantity limit of 15 per 30 days.

Policy contextThese agents are CGRP prophylactic target medications subject to step therapy and the specified claim quantity requirement.

Claims noteClaims not matching the quantity requirement may be denied.

Aimovig / Emgality / Ajovy / Nurtec / (Qulipta mentions) — 15

Listed CGRP agentsAimovig, Emgality, Ajovy, Nurtec (Qulipta also mentioned) — claim must be for quantity of 15 over 30 days.

Step requirement summaryMust try one medication from two different classes (e.g., beta-blockers, tricyclic antidepressants, anti-epileptics, SNRIs) prior to CGRP agents.

Denial riskClaims for these products that do not meet the quantity or prior-step requirements may be denied.

The higher-cost formulary medication for which coverage is sought and that is subject to step therapy requirements.

Coverage conditionCoverage is contingent on documented trial and failure of required step medications per the plan's step sequencing.

Prior authorizationPrior authorization is required when a target medication is subject to step therapy and prior steps have not been met.

Step Medication — definition (placeholder)

Step Medication (term)Used in the document to label medications that must be trialed prior to target medications (appears as 'Step Medication' in the step tables).

Step positionsMedications are assigned to step positions (1, 2, 3) indicating sequence of required trials.

DocumentationProviders must document which step medication(s) were tried and the step level completed when requesting target coverage.

Target Medication — definition (placeholder)

Target Medication (term)Label used throughout the document to indicate medications that require prior step medication trials (appears as 'Target Medication' in the step tables).

Subject to step therapyTarget medications are covered only after required step medication trials/failures are documented.

Prior authorization implicationRequests for target medications generally require prior authorization that documents prior-step failure or contraindication.

Target Medication — Coverage conditioned on prior failure/intolerance of lower-step meds (1,2,3)

Coverage conditionCoverage of a target medication is conditioned on prior failure or intolerance of medications at specified lower step levels (1, 2, or 3).

Step levelsMedications are organized into step levels; a higher-step/target medication requires meeting the lower-step requirements listed.

Documentation requiredMedical records must show trials and failures of the listed lower-step medications (step level documented).

CGRP Prophylactic Step Medication — class-based requirement for migraine prophylaxis

CGRP Prophylactic Step Medication (definition)A class of preventive treatments for migraine where the policy requires trials of specified oral agents (e.g., beta-blockers, tricyclic antidepressants, anti-epileptics, SNRIs) before coverage of CGRP-targeted biologic agents.

Required trial patternMust try at least one medication from two different listed classes prior to CGRP target agents.

Examples of step classesBeta-blockers (propranolol, timolol, metoprolol), tricyclics (amitriptyline, nortriptyline), anti-epileptics (topiramate, divalproex), SNRIs (venlafaxine, duloxetine).

must fail two-step medications — CIC failure requirement

Two-step failure requirement (chronic idiopathic constipation)For chronic idiopathic constipation target agents the policy repeatedly states the patient must 'must fail two-step medications' prior to coverage.

Affected agents (examples)Agents listed include Amitiza, Linzess, Lubiprostone, Motegrity, Trulance, Ibsrela.

DocumentationPrior authorization must include documentation that two prior step medications were tried and failed before the target agent is approved.

must fail two-step medications — definition of two-step failure requirement

Definition: 'must fail two-step medications'A requirement that two prior medications (step medications) be tried and shown ineffective or intolerable before coverage of the target medication is approved.

Common useFrequently applied to chronic idiopathic constipation target medications in this policy.

Prior authorization evidenceMedical records should show trials and failures of the two specified step agents.

Two-step medications — requirement explanation

Explanation of two-step medicationsIndicates that two prior step therapies must be tried and documented as failures before coverage of the target medication for the listed condition.

ScopeUsed across multiple therapeutic areas in the document (notably chronic idiopathic constipation).

Denial riskFailure to document two-step failures may result in denial of coverage.

Terminology mapping — insurer's mapping of preferred step agents to target agents

Terminology mappingThe document maps 'Step Medication' entries to 'Target Medication' entries to indicate the insurer's preferred step agents that must be tried prior to target agents.

Step numberingMedications are assigned step numbers (1–3) in the tables to show sequencing of required trials.

ExamplesExamples include Qbrexza → Drysol/Xarac AC; Uloric → allopurinol; various atypical antipsychotic mappings as shown in the step tables.

Target Medication — placeholder

Target Medication (term) — placeholderUsed in step tables to denote the medication for which coverage is sought after prior step trials are met.

Examples in sourceUloric (febuxostat), Mitigare (colchicine capsule), Qbrexza and others are shown as Target Medications with mapped step agents.

Implicit requirementCoverage of these Target Medications requires documented trials of the associated Step Medications as listed.

Denial triggerClaims that do not meet the quantity or documented prior-step trials may be denied.