CurrentAnthemPolicy N/A

Allergies — Preferred vs Non‑preferred Products (Hot Tip)

Guidance for prescribers on preferred vs nonpreferred oral, nasal, and ophthalmic allergy products, prior authorization and step therapy expectations, and where to verify coverage (Anthem PDL). Affects providers prescribing allergy medications for Anthem members.

Policy Summary

PayerAnthem

PolicyAllergies — Preferred vs Non‑preferred Products (Hot Tip)

Policy CodePolicy N/A

Change TypeHot Tip / informational

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage on the Anthem Preferred Drug List and document required trial(s) of preferred agents before requesting approval for non‑preferred allergy products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drug classes

trial of 2non‑preferred antihistamine trials

trial of 2nasal corticosteroid trials

quarterlyPDL update

Coverage Criteria

Non-preferred agent approval criteria

Approval requirements for non-preferred allergy agents

Non-sedating oral antihistamines (non-preferred): Approval requires trial and failure of BOTH a fexofenadine-containing product AND a loratadine-containing product.trial and failure of 2 specific agents

Some exceptions apply; reference the online searchable formulary for full policy details.

Nasal corticosteroids (non-preferred): Approval requires trial and failure of TWO preferred nasal corticosteroid agents.trial and failure of 2 preferred agents

Some exceptions apply; reference the online searchable formulary for full policy details.

Ophthalmic anti-allergy agents (non-preferred):

Policy Summary

PayerAnthem

PolicyAllergies — Preferred vs Non‑preferred Products (Hot Tip)

Policy CodePolicy N/A

Change TypeHot Tip / informational

Effective DateN/A

Next Review DateN/A

Key ActionVerify coverage on the Anthem Preferred Drug List and document required trial(s) of preferred agents before requesting approval for non‑preferred allergy products.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Requirements

Prior Authorization

Prior authorization / step therapy — PA and step therapy may apply to select preferred products; approval often requires trial/failure

Your Anthem patients on non-preferred products may experience a pharmacy claim rejection. To avoid additional steps or delays at the pharmacy, consider prescribing preferred products whenever possible. Prior authorization and step therapy may apply to select preferred products. Coverage should be verified by reviewing the Preferred Drug List (PDL) on the Anthem provider website. The PDL is subject to change quarterly.

Verify coverage via the Anthem Preferred Drug List (PDL).
Prior authorization (PA) and step therapy may apply to select preferred products.
Document required trials or failures when requesting coverage for non-preferred agents.

Step Therapy

Required step therapy trials — Non-preferred non-sedating antihistamines require trial/failure of both fexofenadine- and loratadine-containing products; non-preferred nasal corticosteroids require trial/failure of 2

Approval of a non-preferred non-sedating antihistamine requires trial and failure of both a fexofenadine- and a loratadine-containing product. Approval of a non-preferred nasal corticosteroid requires trial and failure of two preferred agents. Approval of a non-preferred ophthalmic anti-allergy agent requires trial and failure of all preferred ophthalmic anti-allergy agents. Some exceptions apply; reference the online searchable formulary for full policy details.

Non-preferred non-sedating antihistamines: trial/failure of both fexofenadine- and loratadine-containing products required.
Non-preferred nasal corticosteroids: trial/failure of two preferred agents required.
Non-preferred ophthalmic anti-allergy agents: trial/failure of all preferred ophthalmic agents required.

Documentation Required

Verify coverage and document trials — Verify coverage via Anthem PDL and document trials where required

Verify coverage via the Anthem PDL and document trials where required. When submitting for prior authorization, include documentation of the required trials and dates of therapy to support medical necessity.

Check the online searchable formulary for full policy details and exceptions.
Include dates and outcomes of prior trials when requesting PA to reduce denial risk.

Denial Risk

Claim rejection / PA risk — Prescribing nonpreferred products may cause pharmacy claim rejection; may require prior authorization or step therapy

Prescribing non-preferred products may result in immediate pharmacy claim rejection at point of sale. Such claims often require prior authorization or completion of step therapy prior to approval. To minimize denials and delays, prescribe preferred alternatives when clinically appropriate and confirm PA requirements in advance.

Non-preferred prescriptions may be rejected at the pharmacy point of sale.
A prior authorization or documented step-therapy failures may be required for approval.
Consider prescribing preferred products to avoid claim rejection and delays.

Preferred and Non-Preferred Products

inv-08: Preferred products

Preferred oral antihistamines (PDL)Cetirizine (generic Zyrtec); Cetirizine/pseudoephedrine (generic Zyrtec D); Zyrtec; Zyrtec D; Clarinex (desloratadine)

Preferred nasal corticosteroids (OTC)OTC budesonide nasal spray (generic Rhinocort); OTC Rhinocort Allergy (budesonide); OTC fluticasone propionate (generic Flonase); OTC triamcinolone acetonide (generic Nasacort)

Preferred items noted as OTC where applicableSeveral preferred nasal steroid products are available OTC (budesonide, fluticasone propionate, triamcinolone acetonide)

inv-09: Non-preferred products

Non-preferred oral antihistamines (PDL)Cetirizine (generic Zyrtec); Cetirizine/pseudoephedrine (generic Zyrtec D); Zyrtec; Zyrtec D; Clarinex (desloratadine); Desloratadine (generic Clarinex); Alegra (fexofenadine); Allegra D; Levocetirizine (generic Xyzal); Xyzal; Claritin (loratadine); Claritin D

Non-preferred nasal corticosteroids (PDL)Flonase Sensimist (fluticasone furoate); Flonase (fluticasone propionate) Rx and generic Rx fluticasone propionate; Mometasone furoate (generic Nasonex); Nasacort (triamcinolone acetonide); Nasonex (mometasone furoate); Omnaris (ciclesonide); Qnasl (beclomethasone dipropionate)

Non-preferred combination/decongestant productsCetirizine/pseudoephedrine (Zyrtec D) and Allegra D (fexofenadine/pseudoephedrine) are listed among non-preferred oral products

Background

Summary: This Hot Tip summarizes Anthem's formulary preferences for common allergy medication classes—specifically oral non‑sedating antihistamines, nasal corticosteroids, and ophthalmic anti‑allergy agents—and the approval expectations for non‑preferred products. Key scope points: approval of a non‑preferred non‑sedating oral antihistamine requires trial and failure of both a fexofenadine‑containing product and a loratadine‑containing product; approval of a non‑preferred nasal corticosteroid requires trial and failure of two preferred nasal corticosteroid agents; and approval of a non‑preferred ophthalmic anti‑allergy agent requires trial and failure of all preferred ophthalmic anti‑allergy agents. The document reiterates that some exceptions apply and instructs providers to reference the online searchable formulary for full policy details.