2026 AlohaCare Advantage Plus (HMO D-SNP) Drugs with Step Therapy Requirements
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Defines Aloha Care's step therapy requirements for specific drugs under the 2026 AlohaCare Advantage Plus (HMO D-SNP) plan, specifying required prior therapies before coverage is authorized for listed products.
No material clinical or coverage changes in this revision.
Coverage Criteria and Step Requirements
Actinic keratosis — Initial step requirement
Covered when the following prior therapy is documented
Approve for continuation of prior therapy
Antidepressants — Initial step requirement
Covered when prior trials of formulary generics are documented
Approve for continuation of prior therapy
Atypical antipsychotics — Initial step requirement
Covered when prior trials of formulary atypical antipsychotics are documented
Approve for continuation of prior therapy
Invega Hafyera — Initial step requirement
Covered when prior long-acting formulations are tried (new starts only)
Step applies to new starts only; Approve for continuation of prior therapy
Relistor — Initial step requirement
Covered when prior laxative/agent trials are documented
Rytary - Initial step requirement
Rytary - Covered when the following are met:
Zonisade - Initial step requirement
Zonisade - Covered when the following are met for new starts:
Step applies to new starts only. Approve for continuation of prior therapy.
For Invega Hafyera, the step therapy requirement applies only to new starts. Coverage for new therapy requires documentation of a trial of either Invega Sustenna or Invega Trinza. If the member is already receiving Invega Hafyera as ongoing therapy, the step requirement does not apply and continuation of prior therapy is approved.
For Zonisade new starts, coverage requires documentation of a trial of a generic zonisamide capsule. The step therapy requirement does not apply to members already receiving zonisamide; continuation of prior zonisamide therapy is approved.
Provider Actions, Prior Authorization, and Documentation
Actinic keratosis — prior authorization
Prior authorization requires documentation that the member trialed topical fluorouracil or topical imiquimod before Diclofenac Sodium GEL 3% will be approved.
Antidepressants — prior authorization
Prior authorization requires documentation of trials of two generic formulary antidepressants (from the listed agents) before approving nonpreferred antidepressant products; continuation of prior therapy is approved.
- Required trials from: bupropion; mirtazapine; citalopram; desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline; venlafaxine hydrochloride
Atypical antipsychotics — prior authorization
Prior authorization requires documentation of trials of two oral generic formulary atypical antipsychotics (from the listed agents) before approving specified atypical antipsychotic products; continuation of prior therapy is approved.
- Required trials from: asenapine; aripiprazole; olanzapine; paliperidone; quetiapine; risperidone; ziprasidone
Invega Hafyera — prior authorization
For new starts, prior authorization requires documentation of a trial of Invega Sustenna or Invega Trinza before Invega Hafyera will be approved; continuation of prior therapy is approved without step.
- Step applies to new starts only; approve continuation of prior therapy
Relistor — prior authorization
Prior authorization requires documentation of a trial of one of the specified alternatives (lubiprostone, Constulose, Enulose, Generlac, lactulose, or Movantik) before Relistor will be approved.
Rytary — prior authorization
Prior authorization requires documentation that the member trialed one generic carbidopa/levodopa containing formulation before Rytary will be approved.
Zonisade — prior authorization
For new starts, prior authorization requires documentation of a trial of a generic zonisamide capsule before Zonisade will be approved; existing therapy may be approved for continuation without re-stepping.
- Step applies to new starts only; approve continuation of prior zonisamide therapy
Actinic keratosis — step requirement
A trial of either topical fluorouracil OR topical imiquimod is required before Diclofenac Sodium GEL 3% for actinic keratosis.
- Requirement: 1 trial of either topical fluorouracil or topical imiquimod
Antidepressants — step requirement
A trial of two generic formulary antidepressants (from the listed agents) is required prior to approving specified nonpreferred antidepressant products.
- Requirement: 2 trials from bupropion; mirtazapine; citalopram; desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline; venlafaxine hydrochloride
Atypical antipsychotics — step requirement
A trial of two oral generic formulary atypical antipsychotics (from the listed agents) is required prior to approving specified atypical antipsychotics.
- Requirement: 2 trials from asenapine; aripiprazole; olanzapine; paliperidone; quetiapine; risperidone; ziprasidone
Invega Hafyera — step requirement
For new starts, a trial of Invega Sustenna or Invega Trinza is required before Invega Hafyera will be approved; this step does not apply to continuation of prior therapy.
- Requirement applies to new starts only
Relistor — step requirement
A trial of lubiprostone, Constulose, Enulose, Generlac, lactulose, or Movantik is required prior to approval of Relistor.
Rytary — step requirement
A trial of one generic carbidopa/levodopa containing formulation is required (step 1) before Rytary will be approved.
- Requirement: trial of one generic carbidopa/levodopa formulation
Zonisade — step requirement
For new starts, a trial of a generic zonisamide capsule is required before Zonisade will be approved; the step does not apply to members continuing prior zonisamide therapy.
- Step applies to new starts only; approve continuation of prior therapy
Actinic keratosis — documentation
Document the prior trial of topical fluorouracil or topical imiquimod when requesting Diclofenac Sodium GEL 3% for actinic keratosis.
Antidepressants — documentation
Document trials of two generics from the listed antidepressant agents when requesting affected antidepressant products; continuation of prior therapy is allowed.
Atypical antipsychotics — documentation
Document trials of two oral generic formulary atypical antipsychotics when requesting affected atypical antipsychotic products; continuation of prior therapy is allowed.
Invega Hafyera — documentation
For Invega Hafyera new starts, document a trial of Invega Sustenna or Invega Trinza; if therapy is a continuation, document that to approve without step.
Relistor — documentation
Document prior use of the designated laxatives or agents (lubiprostone, Constulose, Enulose, Generlac, lactulose, Movantik) before requesting Relistor.
Rytary — documentation
Document that the member trialed one generic carbidopa/levodopa formulation when requesting Rytary.
Zonisade — documentation
For new starts of Zonisade, document that the member trialed a generic zonisamide capsule; document continuation of prior therapy to approve without step.
Diclofenac GEL — denial risk
Coverage will be denied for Diclofenac Sodium GEL 3% until a trial of either topical fluorouracil or topical imiquimod is documented.
Antidepressants — denial risk for step requirement
Coverage will be denied unless trials of two listed generic antidepressants are documented prior to approving Emsam, Exxua, Exxua Titration Pack, Fetzima, or Fetzima Titration Pack.
Atypical antipsychotics — denial risk for step requirement
Coverage will be denied unless trials of two oral generic formulary atypical antipsychotics are documented before Fanapt, Fanapt Titration Pack A, Lybalvi, or Secuado are approved.
Invega Hafyera — denial risk for new starts
Coverage for new starts of Invega Hafyera will be denied unless a trial of Invega Sustenna or Invega Trinza is documented; continuation of prior therapy is approved.
Relistor — denial risk
Coverage will be denied unless a trial of lubiprostone, Constulose, Enulose, Generlac, lactulose, or Movantik is documented prior to Relistor.
Rytary — denial risk for prior trial
If a trial of one generic carbidopa/levodopa containing formulation is not documented for Rytary, coverage may be denied.
Zonisade — denial risk for prior trial
If a trial of a generic zonisamide capsule is not documented for new starts of Zonisade, coverage may be denied.
Initial Therapy Criteria (Step 1 Requirements)
Diclofenac Sodium GEL 3% — initial therapy
Antidepressants — initial therapy
Approve continuation of prior therapy
Atypical antipsychotics — initial therapy
Approve continuation of prior therapy
Invega Hafyera — initial therapy
Step applies to new starts only; continuation approved
Relistor — initial therapy
Rytary initial therapy
Zonisade initial therapy
Step applies to new starts only; approve continuation of prior therapy.
Continuation Therapy Guidance
Actinic keratosis — continuation
Continuation guidance when prior therapy exists
Step required for new starts only
Antidepressants — continuation
Continuation guidance for antidepressants
Step applies to new starts; continuation allowed
Atypical antipsychotics — continuation
Continuation guidance for atypical antipsychotics
Step applies to new starts; continuation allowed
Invega Hafyera — continuation
Continuation guidance for Invega Hafyera
Step applies to new starts only
Zonisade continuation
Continuation of prior therapy
Step Therapy Summary Table
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Diclofenac Sodium GEL 3% | Trial of either topical fluorouracil OR topical imiquimod | Covered with criteria |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Emsam; Exxua; Exxua Titration Pack; Fetzima; Fetzima Titration Pack | Trial of two generics from: bupropion, mirtazapine, citalopram, desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine hydrochloride | Covered with criteria (approve continuation of prior therapy) |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Fanapt; Fanapt Titration Pack A; Lybalvi; Secuado | Trial of two oral generic formulary atypical antipsychotic agents: asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone | Covered with criteria (approve continuation of prior therapy) |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Invega Hafyera | Trial of one of: Invega Sustenna OR Invega Trinza (step applies to new starts only) | Covered with criteria (step does not apply to continuation of prior therapy) |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Relistor | Trial of one of: lubiprostone, Constulose, Enulose, Generlac, lactulose, OR Movantik | Covered with criteria |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Rytary | Trial of one generic carbidopa/levodopa containing formulation | Covered with criteria |
| Drug / Group | Step requirement (step 1) | Coverage status |
|---|---|---|
| Zonisade | Trial of a generic zonisamide capsule (step applies to new starts only) | Covered with criteria (approve continuation of prior therapy) |
Background
This policy defines Aloha Care’s step therapy requirements for select drugs under the 2026 AlohaCare Advantage Plus (HMO D‑SNP) plan. It specifies that certain nonpreferred products require documented trials of preferred alternatives before coverage is authorized for new starts (for example, a trial of Invega Sustenna or Invega Trinza before Invega Hafyera, or a trial of a generic zonisamide capsule before Zonisade). Where noted, these step requirements apply to new starts only; members already on the listed therapy are generally eligible for continuation without re‑stepping.
Definitions
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