Currentblue cross blue shield - louisianaPolicy 04HQ3972 R10/23

Fill This First prescription step therapy program

Defines a step therapy program requiring members to try lower-cost Step 1 drugs in specified therapeutic classes before coverage is provided for higher-cost Step 2 drugs; applies to Blue Cross and Blue Shield of Louisiana members served by HMO Louisiana Inc.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyFill This First prescription step therapy program

Policy CodePolicy 04HQ3972 R10/23

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must call Express Scripts at 1-800-842-2015 to request prior authorization for a Step 2 drug when Step 1 drugs are not appropriate or have been tried.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipledrug categories included

Step 1 vs Step 2step structure

1-800-842-2015prior auth phone

Coverage Criteria — Fill This First Step Therapy

Initial Therapy — Covered when ALL of the following are met for new prescriptions:

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Initial coverage conditions: (1) Drug is prescribed in one of the Fill This First program classes; AND (2) Member has tried at least one Step 1 drug in that class for the new prescription or the provider obtains prior authorization for the Step 2 drug because Step 1 drugs are not appropriate; AND (3) Prior authorization approval criteria are satisfied when provider requests Step 2 coverage.

If a Step 2 drug is chosen without first trying required Step 1 drug(s), the Step 2 drug will not be covered and the member may be responsible for full cost; existing users of Step 2 drugs at program start are exempt from switching.

Members who are already taking a Step 2 drug when the Fill This First program is first applied to their plan are not required to switch to a Step 1 drug. This continuation exception applies only to ongoing therapy that began before program implementation; any new prescriptions started after the program effective date are subject to the step therapy requirements and must follow the criteria for trying Step 1 drugs first.

Provider Responsibilities and Authorization

Step Therapy

Step therapy requirement

Try Step 1 before Step 2 — Members must try at least one Step 1 (lower-cost) drug within the listed classes before Step 2 (higher-cost) drugs will be covered for new prescriptions. Ask whether a Step 1 drug is appropriate at the time of prescribing.

Step 1 drugs = generics and other lower-cost options in the listed drug classes.
Step 2 drugs = higher-cost drugs that have Step 1 alternatives.

Prior Authorization

Prior authorization required for Step 2

Prior authorization is required for Step 2 drugs when Step 1 drugs have not been tried or when the provider documents that Step 1 drugs are not appropriate. Providers must submit clinical justification when requesting authorization for a Step 2 medication.

To request prior authorization, providers must call Express Scripts at 1-800-842-2015.
Authorization may be granted if clinical criteria show Step 1 drugs are not appropriate for the member.

Note

How to obtain authorization

Prior authorization contact — Providers must call Express Scripts at 1-800-842-2015 to request prior authorization for a Step 2 drug when they determine Step 1 drugs are not appropriate or have not been tried.

Have clinical documentation available to support why Step 1 therapy is inappropriate or has failed.

Denial Risk

Denial risk if Step 1 is not tried

Coverage denial if Step 1 not tried — If a Step 2 drug is selected without first trying required Step 1 drug(s) and prior authorization is not approved, the Step 2 drug will not be covered and the member will be responsible for the full cost.

If prior authorization is denied because required Step 1 therapy was not tried or criteria are not met, coverage for the Step 2 drug will be denied.

Step Therapy Operational Rule

Requirement	Details
Try at least one Step 1 drug before Step 2 coverage for new prescriptions
Members must try at least one lower-cost Step 1 drug in the listed Fill This First classes before a higher-cost Step 2 drug will be covered for a new prescription. Generics and other lower-cost options are considered Step 1; higher-cost drugs with Step 1 alternatives are Step 2.
Prior authorization option when Step 1 is not appropriate or previously tried
If a provider determines Step 1 drugs are not appropriate or the member has already tried one or more Step 1 drugs, the provider may call Express Scripts at 1-800-842-2015 to request prior authorization for Step 2 coverage. Prior authorization is required when Step 1 drugs have not been tried or are not appropriate.
Coverage denial if Step 1 not tried and no prior authorization
If a Step 2 drug is selected without first trying required Step 1 drug(s), and prior authorization is not obtained/approved, the Step 2 drug will not be covered and the member will be responsible for the full cost.

Existing Step 2 Users

Existing Step 2 Users — Ongoing users of Step 2 drugs at program implementation

Ongoing users of Step 2 drugs at program implementation

Continuation: Members already taking a Step 2 drug when the program is first applied to their plan may continue that drug without having to try Step 1 alternatives.

Applies only to therapy already ongoing at program start; any new prescriptions after program start are subject to step requirements.

Key Terms

Step 1 — lower-cost, effective drugs (typically generics) that members should try first

DefinitionStep 1 = lower-cost, effective drugs (typically generics) that members should try first for new prescriptions in specified drug classes.

PurposeDesigned to encourage effective, lower-cost treatment options before higher-cost alternatives are used.

ApplicabilityApplies to new prescriptions within the Fill This First program drug classes; generics and other lower-cost drugs are Step 1.

Step 2 — higher-cost drugs that have lower-cost Step 1 alternatives and may require prior authorization if Step 1 drugs have not been tried

DefinitionStep 2 = higher-cost drugs that have lower-cost Step 1 alternatives and may require prior authorization if Step 1 drugs have not been tried.

Prior authorizationPrior authorization may be required for Step 2 drugs when a Step 1 drug has not been tried for a new prescription.

Coverage conditionStep 2 drugs are covered for new prescriptions only after required Step 1 therapy is tried or when prior authorization documents Step 1 is not appropriate.

Policy Background

Step therapy is applied to new prescriptions in specified chronic condition drug classes to encourage effective, lower-cost treatment options be tried first. Step 1 drugs are lower-cost, effective options (typically generics) that members should try before higher-cost alternatives. Members already using a Step 2 drug when the program is first applied to their plan may continue that therapy without switching, but any new drug prescriptions after program implementation must follow the Fill This First step requirements.