Prior auth: Diclofenac 3% — document topical alternative trial

Prior authorization requires documentation that the member has previously tried either topical fluorouracil or topical imiquimod before Diclofenac Sodium GEL 3% will be approved.

• Step therapy requirement: trial of either topical fluorouracil OR topical imiquimod must be documented.

Prior auth: Branded antidepressants — document two generic trials

Prior authorization requires documentation of trials of two generic antidepressant formulary products from the specified list (bupropion; mirtazapine; citalopram; desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline; venlafaxine HCl) before covering listed branded antidepressants; continuation of prior therapy is approved.

• Document two trials from the enumerated generic antidepressants.
• Continuation of prior therapy for listed products may be approved.

Prior auth: Atypical antipsychotics — document two generic trials

Prior authorization requires documentation of trials of two oral generic formulary atypical antipsychotics (asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone) before Fanapt, Lybalvi, or Secuado will be approved; continuation of prior therapy is approved.

• Document trials of two of the listed generic atypical antipsychotics.
• Continuation of prior therapy for these products may be approved.

Prior auth: Invega Hafyera — trial of Sustenna or Trinza for new starts

For new starts of Invega Hafyera, prior authorization requires documentation of a trial of Invega Sustenna or Invega Trinza; continuation of existing therapy should be approved.

• Step applies to new starts only: document trial of Invega Sustenna OR Invega Trinza.
• Approve continuation for members already on therapy.

Prior auth: Relistor — document trial of listed laxatives

Prior authorization requires documentation of a trial of one of the listed laxatives (lubiprostone, Constulose, Enulose, Generlac, or lactulose) before Relistor will be approved.

• Document trial of lubiprostone OR Constulose OR Enulose OR Generlac OR lactulose prior to Relistor.

Prior auth: Rytary — document generic carbidopa/levodopa trial

Prior authorization requires documentation that the member tried one generic carbidopa/levodopa containing formulation before Rytary will be approved.

• Document trial of one generic carbidopa/levodopa formulation prior to Rytary.

Step therapy prior auth — document required step trials

Prior authorization decisions require documentation that the specified step therapy trial(s) of preferred generic alternatives were completed before approving the branded products; for Zonisade continuation requests, members already on therapy should be approved.

• Document the exact step trial(s) specified for the product (e.g., generic alternatives listed per drug).
• Continuation requests for members already on Zonisade should be approved.

Step: Actinic keratosis — trial of fluorouracil or imiquimod required

Step therapy requires a documented trial of either topical fluorouracil or topical imiquimod before Diclofenac Sodium GEL 3% is covered.

• Document trial of either topical fluorouracil OR topical imiquimod for actinic keratosis prior to diclofenac gel 3%.

Step: Antidepressants — two generic trials required

Step therapy requires documentation of trials of two generics from the specified antidepressant list before covering the listed branded antidepressants; continuation of prior therapy is acceptable.

• Trials must be from the enumerated generics: bupropion; mirtazapine; citalopram; desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline; venlafaxine HCl.
• Continuation of prior therapy for listed products may be approved.

Step: Atypical antipsychotics — two generic trials required

Step therapy requires documentation of trials of two listed oral generic atypical antipsychotics (asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone) before Fanapt, Lybalvi, or Secuado; continuation of prior therapy is acceptable.

• Document trials of two of the listed generics.
• Continuation of prior therapy for these products may be approved.

Step: Invega Hafyera — trial of Sustenna or Trinza for new starts

For new starts of Invega Hafyera, step therapy requires a trial of Invega Sustenna or Invega Trinza; continuation of prior therapy is allowed.

• Step applies to new starts only: document trial of Invega Sustenna OR Invega Trinza.
• Approve continuation of prior therapy for existing users.

Step: Relistor — trial of listed laxatives required

Step therapy requires a documented trial of one of the listed laxatives (lubiprostone, Constulose, Enulose, Generlac, or lactulose) before Relistor is covered.

• Document trial of lubiprostone OR Constulose OR Enulose OR Generlac OR lactulose prior to Relistor.

Step: Rytary — trial of generic carbidopa/levodopa required

Step therapy requires a documented trial of one generic carbidopa/levodopa containing formulation before Rytary is covered.

• Document trial of one generic carbidopa/levodopa formulation prior to Rytary.

Rytary step — trial of generic carbidopa/levodopa formulation

Restatement: the Rytary step specifically requires a trial of one generic carbidopa/levodopa formulation prior to approval of Rytary.

• Failure to meet this trial may lead to denial (see denial risk).

Step: Zonisade — trial of generic zonisamide capsule for new starts

Step therapy for Zonisade requires a documented trial of a generic zonisamide capsule for new starts only; approve continuation of prior therapy for members already receiving Zonisade.

• Step applies to new starts only: document trial of a generic zonisamide capsule.
• Continuation of prior therapy for existing members should be approved.

Documentation: Actinic keratosis — record trial of fluorouracil or imiquimod

Document the member’s trial of either topical fluorouracil or topical imiquimod before approving Diclofenac Sodium GEL 3% for actinic keratosis.

• Include documentation showing use of topical fluorouracil OR topical imiquimod prior to diclofenac gel 3%.

Documentation: Antidepressants — record two generic trials or prior therapy

Document trials of two generics from the specified antidepressant list, or document continuation of prior therapy when applicable, before approving the listed branded antidepressants.

• Record which two generic antidepressants from the enumerated list were tried and dates/duration.
• If continuing prior therapy, document existing therapy details.

Documentation: Atypical antipsychotics — record two generic trials or prior therapy

Document trials of two generic atypical antipsychotics from the specified list, or document continuation of prior therapy, before approving Fanapt, Lybalvi, or Secuado.

• Record which two generic atypical antipsychotics were tried and dates/duration.
• If continuing prior therapy, document existing therapy details.

Documentation: Invega Hafyera — record trial for new starts or prior therapy for continuation

For Invega Hafyera new starts, document trial of Invega Sustenna or Invega Trinza; for continuation requests, document existing prior therapy to support approval.

• Document trial of Invega Sustenna OR Invega Trinza for new starts.
• For continuation, document prior therapy details to allow approval.

Documentation: Relistor — record trial of listed laxatives

Document trial of one of the listed laxatives (lubiprostone, Constulose, Enulose, Generlac, or lactulose) before approving Relistor.

• Record which laxative was tried and dates/duration prior to Relistor.

Documentation: Rytary — record generic carbidopa/levodopa trial

Document a trial of one generic carbidopa/levodopa containing formulation prior to approving Rytary; supporting documentation of the trial is required to meet step therapy criteria.

• Record which generic carbidopa/levodopa formulation was tried and dates/duration.
• Lack of this documentation may result in denial.

Required supporting documentation — record the specified trial per plan

Documented trial evidence as specified in each product’s step requirement (for example, the named generic alternative or formulation) is required to meet step therapy criteria for approval.

• Provide documentation matching the plan’s stated trial requirement (e.g., generic carbidopa/levodopa formulation; generic zonisamide capsule).
• Ensure dates and duration of trials are included.

Denial risk: failure to document step therapy trials

Coverage of listed drugs may be denied if the required prior trial(s) of preferred agents (step therapy) are not documented.

• Failure to provide required step trial documentation can result in denial of coverage.

Denial risk: Rytary — missing generic carbidopa/levodopa trial

Failure to document a trial of one generic carbidopa/levodopa formulation as required may trigger denial for Rytary prior authorization or step therapy requests.

• Ensure documentation of the specified generic carbidopa/levodopa trial to avoid denial.

Denial risk: Zonisade — missing generic zonisamide trial for new starts

For new starts of Zonisade, lack of documented trial of a generic zonisamide capsule may trigger denial; continuation requests for members already on therapy should be approved.

• New starts: document trial of a generic zonisamide capsule to meet step requirement.
• Continuation: approve when prior therapy is documented.