Formulary utilization management: step therapy requirements for selected drugs
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Defines step therapy and prior authorization requirements applied to specific outpatient prescription drugs on the AmeriHealth Medicare PPO formulary; affects prescribers and pharmacies serving AmeriHealth Medicare PPO members.
No material clinical or coverage changes in this revision.
Coverage criteria for step therapy and prior authorization
Fetzima — Step therapy (new starts)
Covered when required trials of formulary alternatives are documented for new starts.
from product list
Fanapt — Step therapy (new starts)
Covered when required trials of formulary alternatives are documented for new starts.
from product list
Drizalma — Step therapy (new starts)
Covered when required trial is documented.
from product list
Eprontia — Step therapy (new starts)
Covered when required trials of formulary alternatives are documented.
from product list
Exxua — Step therapy (new starts)
Covered when required trials of formulary alternatives are documented for new starts.
from product list
Basaglar — Step therapy
Covered when required trials of formulary alternatives are documented.
from product list
Rebif — Step therapy (new starts)
Covered when required trials of formulary alternatives are documented for new starts.
from product list
Relistor — Step therapy
Covered when required trials are documented.
from product list
Sancuso, Savella, Xcopri — Step therapy
Covered when required trials of formulary alternatives are documented for new starts.
from product list
from product list
Zonisade suspension — Step therapy (new starts)
Covered when required trial of formulary alternatives is documented for new starts.
from product list
This policy lists specific step therapy (ST) requirements that apply to selected outpatient prescription drugs on the AmeriHealth Medicare PPO formulary. For each listed product the plan requires documentation that the member has tried the specified generic formulary alternative(s) before the non‑preferred or brand product will be covered. Many entries explicitly apply to new treatment starts (initial therapy) and commonly require trials of one to two formulary alternatives; product‑level details (which alternatives and whether two trials are required) are provided in the corresponding criteria entries (for example: Fetzima, Fanapt, Drizalma, Eprontia, Exxua, Rebif, Relistor, Sancuso/Savella/Xcopri, Zonisade, Basaglar).
The document does not list clinical coverage exclusions within these criteria. Providers may request an exception to plan utilization management requirements or obtain information about alternative therapies via the member's Formulary (List of Covered Drugs) and Evidence of Coverage; additional PA requirements and the full exception process are referenced in those plan materials.
Initial therapy / new starts
Initial therapy / new starts
Apply the following top‑level requirement for initial therapy (new starts):
See product‑specific entries
Step therapy specifics and product table
| Product | Required trial(s) of formulary alternative(s) | Applies to |
|---|---|---|
| Fetzima (ER capsule, multiple strengths) | Trial of two of the following generic formulary SNRIs: desvenlafaxine tablet, duloxetine capsules, venlafaxine HCl immediate‑release tablets, venlafaxine HCl capsules. | Applies to new starts |
| Fanapt (various strengths) | Trial of two generic formulary antipsychotic products. | Applies to new starts |
| Drizalma (sprinkle capsule, various strengths) | Trial of generic formulary duloxetine. | Applies to new starts |
| Eprontia (solution) | Trial of generic formulary immediate‑release pregabalin or topiramate (capsules or solution). | Applies to new starts |
| Exxua (ER tablet, multiple strengths) | Trial of two of the following: bupropion, citalopram tablets, desvenlafaxine ER, duloxetine capsules, escitalopram tablets, fluoxetine, mirtazapine, paroxetine IR, sertraline tablets, venlafaxine IR/ER. | Applies to new starts |
| Basaglar KwikPen (insulin pen) | Trial of two of the following: Lantus, Toujeo, Tresiba. | Always applies |
| Rebif products (various injectables) | Trial of two of the following formulary products: Avonex, Betaseron, Glatopa, Tecfidera, Gilenya, teriflunomide. | Applies to new starts |
| Relistor (solutions and tablet) | Trial of lubiprostone or lactulose. | Always applies |
| Sancuso patch | Trial of (a) ondansetron or granisetron AND (b) aprepitant. | Always applies |
| Xcopri (multiple tablet strengths/therapy packs) | Trial of two generic formulary anticonvulsants. | Applies to new starts |
| Zonisade suspension 100 mg/5 mL | Trial of generic zonisamide capsule. | Applies to new starts |
What prescribers and pharmacies must do
Prior Authorization Required
Certain drugs require prior authorization (PA). Prescribers must obtain plan approval before the prescription is filled. If prior authorization is not obtained, the plan may deny coverage and the member may be responsible for the drug cost.
- See 2026 Utilization Management Criteria: Prior Authorization for the full PA drug list and submission details.
Prior Authorization Denial Risk
Failure to obtain required prior authorization or to meet step therapy requirements may result in denial of coverage for the prescription. Prescribers should obtain PA and document required trials before submitting claims to avoid non‑coverage.
- Non‑coverage can occur at point of fill if PA is not in place.
- Documented prior trials required for step therapy must be available upon request.
Step Therapy Requirements
Step therapy (ST) requires trial of specified generic formulary alternatives before coverage of certain listed products. For example, new starts for several antidepressants require trial of two specified generic SNRIs or SSRIs; anticonvulsant and antipsychotic products similarly require trials of listed generic formulary alternatives.
- Examples: Trial of two generic formulary SNRIs (desvenlafaxine, duloxetine, venlafaxine IR/ER) required for Fetzima new starts.
- Trial of two generic formulary antipsychotics required for Fanapt new starts.
- Trial of two generic anticonvulsants required for Xcopri new starts.
- Trial of generic zonisamide required for Zonisade new starts.
Where to Find Documentation
Find full details of prior authorization, step therapy, quantity limits, and the affected drug lists in your plan Formulary (List of Covered Drugs) and the 2026 Utilization Management Criteria: Prior Authorization. Visit www.amerihealthmedicare.com or contact AmeriHealth Medicare PPO Member Help at 1‑866‑569‑5190 (TTY 711) for assistance.
- Formulary (List of Covered Drugs) — check the 'Requirements' column (look for 'ST', 'PA', 'QL').
- 2026 Utilization Management Criteria: Prior Authorization — contains PA submission requirements and full PA drug list.
Key definitions
Background and scope
This document summarizes the utilization management controls applied to specific outpatient drugs on the AmeriHealth Medicare PPO formulary. The primary controls are Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL). Prior Authorization requires plan approval before dispensing certain drugs; without approval the plan may not cover the medication. Step Therapy requires that specified formulary alternatives be tried first (commonly 1–2 agents) before the listed product is covered, with many step edits targeted to new starts. Quantity Limits restrict the amount of medication the plan will cover for certain products.
Providers should use this document together with the plan Formulary and the 2026 Utilization Management Criteria: Prior Authorization for details on PA requirements, the exact formulary alternatives referenced in step therapy entries, and the process for exceptions or documentation submission.
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