Prior authorization and step therapy criteria for formulary drugs
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This document lists medications on the BCN Advantage HMO-POS Comprehensive Formulary that require prior authorization (PA) or step therapy (ST), and specifies clinical/administrative coverage criteria affecting prescribers and members.
No material clinical or coverage changes in this revision.
Coverage Criteria (Product-specific)
Adbry (Atopic dermatitis) - Initial and reauthorization
Covered when ALL of the following are met:
Prior authorization required; reauthorization requires documentation of positive clinical response; for patients <100 kg who achieve positive response after 16 weeks dosage limited to 300 mg every 4 weeks unless clinical rationale provided.
Coverage duration 1 year; cannot be used in combination with another biologic/targeted DMARD indicated for the same condition.
Selected prior therapy/combination requirements
Examples of prerequisite trial or combination requirements used across listed products:
Example: everolimus + exemestane requirement (chunk 3).
See product-specific entries (chunk 72).
Example: calcipotriene entry (chunk 18).
Examples: Cimzia, Simponi, Taltz entries (chunks 22,146,160).
See chunks 14 and 29 for examples.
Cimzia — coverage with criteria
Covered when ALL of the following are met:
Coverage duration 1 year; reauthorization requires documentation of positive clinical response.
Per Cimzia RA criteria (chunk 22).
Per Cimzia PsA criteria (chunk 22).
Cosentyx — coverage with criteria
Covered when ALL of the following are met:
Coverage duration 1 year; reauthorization requires documentation of positive clinical response.
Per Cosentyx axial disease criteria (chunk 26).
Dalfampridine — coverage with criteria
Covered when ALL of the following are met:
Excluded if patient is wheelchair bound or becomes wheelchair bound; reauthorization requires documentation of stability or improvement on T25FW (chunk 28).
Dupixent — indication-specific criteria
Covered when ALL of the following, indication-specific requirements are met:
Coverage duration 1 year; reauthorization requires documentation of positive clinical response.
Applies for patients ≥2 years per product entry (chunks 32/33).
Chunk 32/33
Chunk 33
Copaxone / Glatiramer products
Covered when ALL of the following are met:
Coverage duration typically 1 year per group listing.
Daurismo (glasdegib) — AML combination requirement
Covered when ALL of the following are met:
Per product criteria (chunk 29).
Diacomit — anticonvulsant prerequisite
Covered when ALL of the following are met:
Per Diacomit entry (chunk 30).
L-glutamine — sickle cell criteria
Covered when ALL of the following are met:
Per L‑glutamine product entry (chunk 37).
RA initial coverage — rheumatoid arthritis products with prerequisite therapy
Covered when ALL of the following are met:
Coverage duration commonly 1 year (chunk 36).
JIA initial coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 36).
Eosinophilic asthma coverage
Covered when ALL of the following are met:
Reauthorization requires documentation of positive clinical response (chunks 44–45).
EGPA coverage
Covered when ALL of the following are met:
Reauthorization requires documentation of positive clinical response (chunk 44).
Cannabidiol (Epidiolex) coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 38).
Topiramate coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 39).
Osteoporosis criteria
Covered when ALL of the following are met:
Some products require trial of Jubbonti or Stoboclo and an oral bisphosphonate (see chunk 49).
Gattex criteria
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 51).
Gilotrif coverage
Covered when ALL of the following are met:
Mutation testing required (chunk 53).
GLP-1 agent coverage
Covered when ALL of the following are met:
Excluded if used for weight‑loss only (chunk 54).
T2DM indication requirements
Covered when ALL of the following are met:
Per GLP‑1/T2DM documentation requirements (chunk 54).
Biologics — RA, JIA, AS, IBD coverage criteria
Rheumatologic/autoimmune biologics — Covered when ALL of the following are met:
Applies across rheumatologic biologics (chunks 58,59).
See individual product entries for required number/type of prior agents (chunks 58,59,36).
Oncology agent coverage criteria
Oncology/specialty targeted agents — Covered when ALL of the following are met:
Chunk 60
Chunk 66
APDS (Joenja) coverage criteria
Covered when ALL of the following are met:
Cannot be used in combination with an immunosuppressive medication (chunk 71).
Product-specific coverage criteria (selected examples)
Product-specific examples — each entry summarizes the primary prerequisite or condition required for initial coverage:
Chunk 72
Chunk 74
Chunk 76
Chunks 90,93,95
Chunk 133
Mekinist coverage criteria
Mekinist coverage — covered when ALL of the following are met:
Coverage duration 1 year; liquid formulation covered only if patient unable to swallow tablets (chunks 90,93).
Chunks 90,93,94
Mektovi coverage criteria
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 95).
Nucala coverage criteria
Nucala is covered when ANY of the indication-specific criteria below are met:
Reauthorization requires documentation of positive clinical response (chunks 104,106).
Applies to adults and children ≥12 years (chunks 104,106).
Chunk 104/106
Nurtec criteria
Covered when ALL of the following are met:
Initial coverage period and reauthorization per product entry (chunk 98).
Nexletol/Nexlizet criteria
Covered when ALL of the following are met:
Examples and statin intolerance considerations provided in product entry (chunks 100–101).
Acute migraine products - coverage conditions
Covered when ALL of the following are met:
Applies to listed acute migraine products (chunk 108).
Posaconazole DR - prophylaxis and treatment coverage
Covered when ALL of the following are met:
Coverage duration 6 months (chunk 122).
Chunk 122
Opfolda - Pompe disease coverage
Covered when ALL of the following are met:
Per Opfolda criteria (chunk 111).
Orencia - autoimmune indications
Covered when ALL of the following are met:
Reauthorization requires documentation of positive clinical response and that abatacept is not combined with other immunosuppressives (chunk 113).
Chunk 113
Orenitram - pulmonary arterial hypertension
Covered when ALL of the following are met:
Chunk 114
Praluent - lipid disorders (initiation and reauthorization)
Covered when ALL of the following are met:
Reauthorization requires continued statin if tolerated and documented LDL reduction; coverage duration 3 years (chunk 125).
Jubbonti and Stoboclo - osteoporosis-related coverage
Covered when ALL of the following are met:
Coverage duration 3 years; explicit exclusion for hypocalcemia (chunk 127).
Piqray - PIK3CA-mutated breast cancer
Covered when ALL of the following are met:
Per Piqray criteria (chunk 119).
Otezla - psoriatic/psoriasis coverage
Covered when ALL of the following are met:
Reauthorization requires documentation of positive clinical response (chunk 116).
General reauthorization/coverage durations
General notes on authorization and duration across products:
See individual product entries for specific durations (chunk 118).
Prevymis coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 126).
Jubbonti / Stoboclo coverage
Covered when ALL of the following are met:
Coverage duration 3 years (chunk 127).
Eltrombopag coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 128).
Lenalidomide coverage
Covered when ALL of the following are met:
Prescribed by or in consultation with an oncologist/hematologist; coverage duration 1 year (chunk 133).
Rezdiffra coverage and renewal
Covered when ALL of the following are met:
Renewal requires no progression to cirrhosis and specified evidence of improvement or stabilization (chunk 135).
Rezurock coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 136).
Rinvoq coverage
Covered when ALL of the following are met:
Coverage duration 1 year; prerequisite Part D drug required where indicated (chunks 137–139).
Chunk 137–139
Rivfloza coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 140).
Rybrevant coverage
Covered when ANY of the following indication‑specific conditions are met:
Coverage duration 1 year (chunk 142).
Rydapt coverage
Covered when ALL of the following are met:
Coverage duration 1 year (chunk 143).
Tolvaptan coverage
Covered when ALL of the following are met:
Coverage duration 1 month; prerequisite Part D drug required (chunk 144).
Secuado coverage
Covered when ALL of the following are met:
Coverage duration listed as lifetime (chunk 145).
Initial criteria (example product)
Example product initial-coverage pattern (illustrative entry from document):
From illustrative example in chunk 144.
Simponi — indication-specific criteria
Simponi covered when ALL indication‑specific prerequisites are met:
Reauthorization requires documentation of positive clinical response (chunks 146–147).
Chunks 146–147
Stivarga — colorectal cancer
Stivarga is covered when ALL of the following are met:
Per Stivarga CRC criteria (chunk 153).
Tagrisso — indication-specific coverage
Tagrisso is covered when ANY of the indication‑specific conditions below are met:
Chunk 159
Chunk 159
Chunk 159
Talzenna / Erlotinib coverage highlights
Covered when ALL of the following are met:
Coverage duration one year (chunk 162).
Prescriber should be an oncologist; coverage duration 1 year (chunk 162).
Actemra
Actemra coverage requires ALL of the following:
Chunk 169
Tetrabenazine
Tetrabenazine coverage constraints and exclusions — ALL must be met:
CYP2D6 genotype documentation required for doses >50 mg/day (chunk 166).
Verquvo — Heart failure initial therapy
Covered when ALL of the following are met:
Must be taken with at least two guideline heart failure therapies unless contraindicated; coverage duration 1 year (chunk 180).
Chunk 180
Verzenio covered indications
Verzenio covered indications — ANY of the following:
Coverage duration 1 year (chunk 182).
Chunk 182
Chunk 182
Chunk 182
H. pylori treatment criteria
H. pylori treatment — covered when ALL of the following are met:
Coverage duration 1 year (chunk 184).
Voydeya coverage criteria
Voydeya is covered when ALL of the following are met:
Coverage duration 1 year (chunk 187).
Xolair covered indications and criteria
Xolair covered indications — ANY of the following when prerequisites met:
Reauthorization requires documentation of positive clinical response (chunks 197–198).
Chunk 197/198
Chunks 197–198
Xermelo coverage criteria
Covered when ALL of the following are met:
Chunk 196
Oncology agent coverage criteria (prior‑line requirements)
Oncology prior‑line / line‑of‑therapy requirements (examples):
See chunk 200 for examples.
Chunk 203
Product-specific prerequisite trials
Product‑specific prerequisite trials required for initial coverage (selected entries):
Chunks 212–214.
Chunk 216/217.
Chunks 235,237,239,243.
Chunks 241,245.
Chunk 249.
Chunk 251.
Chunk 253.
Product-specific initial coverage criteria — prerequisite trials and step therapy
Selected initial‑therapy step requirements (examples):
Chunk 217.
Chunk 219.
Chunk 221.
Chunk 231.
Chunk 251.
General reauthorization/continuation rules
Reauthorization/continuation requirements — covered when ALL of the following are met:
Chunk 2
Chunk 28
Chunks 23,36,147,152
Chunk 125
| No codes listed |
Adbry (dupilumab) is not eligible for coverage when prescribed in combination with another biologic or targeted DMARD indicated for the same condition. This combination exclusion is explicit in the product-specific criteria and applies to initial and continuation authorizations for Adbry. Documentation of prior therapies and reauthorization requirements remain applicable when Adbry is used as a single biologic agent.
Budesonide extended release is not covered for maintenance of remission in ulcerative colitis. The policy explicitly excludes this use and limits coverage to the product’s indicated, non-maintenance scenarios as specified in the formulary entry.
Tadalafil is contraindicated for concomitant use with nitrate therapy; the policy states coverage is not provided when the patient is receiving nitrate therapy. Confirm active medication lists for nitrates before approving tadalafil.
Dalfampridine is excluded for patients who are wheelchair bound or who become wheelchair bound. A baseline Timed 25-Foot Walk (T25FW) must be submitted prior to initiation, and reauthorization requires documentation of stability or improvement on the T25FW.
For biologic therapies and other targeted DMARDs across multiple product entries, the policy consistently disallows combination use of one agent with another biologic or targeted DMARD indicated for the same condition. Requests that propose concurrent use of two such agents for the same diagnosis are excluded and may be denied.
Coverage of Diacomit for seizures associated with Dravet syndrome requires concomitant use with clobazam. The policy specifies that Diacomit is not sufficient as monotherapy for Dravet-related seizures and requires that clobazam be used in combination.
Initial Therapy / Start-of-Care Criteria
| Product | Step requirement |
|---|---|
| Auvelity requires a trial of bupropion and one other generic formulary antidepressant prior to coverage for major depressive disorder (step therapy). | |
| Step therapy applies: prerequisite Part D drug required as listed in product entry. |
| Product | Step requirement |
|---|---|
| Requires prior trial of at least one generic topical steroid before coverage. |
| Example product / class | Step requirement (summary) |
|---|---|
| Requires trials of specified alternative biologics/DMARDs per indication (e.g., trial of two listed alternatives for RA, PsA, plaque psoriasis, AS) prior to coverage; cannot be used in combination with another biologic/targeted DMARD for same condition. | |
| Many biologics require prior trials of specified alternative biologics or conventional therapies (often two listed alternatives) before coverage; combination use with another biologic/targeted DMARD for the same condition is not allowed. |
| Product / indication | Step requirement |
|---|---|
| For migraine prevention: trial of at least 2 generic alternatives for migraine prevention (or inability to swallow tablets/capsules). For seizure disorder: trial of at least 2 generic anticonvulsants (or inability to swallow tablets/capsules). | |
| Coverage requires trial of 2 generic anticonvulsant alternatives; for Dravet specifically trial of 2 of valproic acid, clobazam, or topiramate. | |
| Acute migraine agents require trial of at least two generic triptans (e.g., sumatriptan, rizatriptan) prior to coverage unless contraindicated or not tolerated. |
| Product | Step requirement |
|---|---|
| Requires trials of Jubbonti or Stoboclo AND an oral bisphosphonate (or IV bisphosphonate if intolerant) prior to coverage; documentation of BMD T-score ≤ -2.5 required. |
Reauthorization / Continuation Criteria
Provider Actions, Documentation & Denial Risks
Prior authorization required for listed drugs
Many formulary drugs listed in this section require prior authorization (PA); clinical and/or administrative criteria must be met before coverage is provided. Submit PA requests and supporting records that document the diagnosis, age, prior therapy trials, and any required test results per the product-specific criteria.
- PA applies to numerous listed products; check individual product entries for prerequisites and exclusions.
- Unless otherwise noted, authorization durations are commonly 1 year for covered products.
Test documentation required when specified
For some products the PA request must include specific diagnostic test documentation (example: documentation that the member passed the Bronchitol tolerance test when required). Provide the exact test results or lab reports cited in the product criteria.
- Attach relevant laboratory or diagnostic test reports when specified by the product criteria.
- Failure to include required test documentation may delay or prevent approval.
Prior authorization and authorization duration
A prior authorization is required for most listed specialty agents; unless a different duration is specified in the product entry, approvals are typically issued for one year.
- Check the product entry for any exceptions to the standard one‑year authorization duration.
- If a shorter duration is specified (e.g., Tolvaptan = 1 month), follow the product-specific timeframe.
Cimzia — PA requires prior biologic/DMARD trials and reauthorization response
Cimzia (certolizumab pegol) requires prior authorization and, for many indications, trials of specified alternative biologics/DMARDs before approval; reauthorization requires documentation of positive clinical response.
- For RA, PsA, plaque psoriasis and related indications, document trials of the listed alternative agents and that Cimzia is not being used in combination with another biologic/targeted DMARD.
- Include clinical notes showing positive response for reauthorization.
Reauthorization requires documentation of positive clinical response
Reauthorization of many biologic and specialty products requires submission of medical records documenting a positive clinical response to the therapy (e.g., symptom improvement or objective test improvement).
- Include clinician progress notes, objective measurements, or test results demonstrating benefit when requesting renewal.
- Lack of documented positive clinical response may result in denial at reauthorization.
Prior authorization requires submission of medical-record evidence
PA requests must include supporting medical-record evidence that confirms the requested indication and any required laboratory or diagnostic data (for example, documentation of T2DM or A1c values when required for GLP‑1 coverage).
- Attach chart notes, lab reports (A1c, FPG, OGTT), imaging, genetic test results, or procedure reports as specified by the product criteria.
- Incomplete or missing medical-record evidence may lead to denial or request for more information.
Prior trials required for rheumatologic/autoimmune indications
For rheumatologic and other autoimmune biologics, prior authorization commonly requires documented trials of specified conventional therapies (e.g., DMARDs for RA/JIA or an NSAID for AS) before biologic therapy is approved.
- Document prior DMARD trials (e.g., methotrexate, leflunomide, sulfasalazine) or NSAID use as applicable to the indication.
- If a prior TNF inhibitor or other biologic is required, include therapy start/stop dates and reason for failure or intolerance.
Mektovi — PA requires combination with encorafenib and mutation confirmation
Mektovi coverage requires prior authorization and must be used in combination with encorafenib for unresectable or metastatic melanoma with BRAF V600E/V600K mutations; document the BRAF mutation and prior trial(s) as specified.
- Attach results of an FDA‑approved test showing the BRAF V600E or V600K mutation.
- Include records showing the required trial of vemurafenib + cobimetinib where specified and that the combination with encorafenib will be used.
Acute migraine step requirement — trial of two generic triptans
Nurtec, Ubrelvy, and other acute migraine agents require prior trial of at least two generic triptans (e.g., sumatriptan, rizatriptan) unless triptan therapy is contraindicated, not tolerated, or clinically inappropriate; include trial documentation.
- Document dates, dosages, and response/intolerance for the two triptan trials.
- If triptan trials are contraindicated, provide clinical rationale.
Posaconazole DR — PA requires risk justification and trial of two alternative azoles
Posaconazole DR prior authorization for prophylaxis/treatment requires documentation of the high‑risk condition and trials of two alternative azoles (fluconazole, itraconazole, or voriconazole) as specified.
- Attach infectious disease or transplant documentation indicating HSCT with GVHD, prolonged neutropenia, or prior fungal infection requiring secondary prophylaxis.
- Include records of the two alternative azole trials.
Praluent — PA requires statin trial and LDL documentation
Praluent prior authorization requires documentation of ASCVD/primary hyperlipidemia/HeFH criteria, trial of high‑intensity statin at maximally tolerated dose (or documented statin intolerance), and LDL thresholds measured within the prior 120 days.
- Provide LDL values while on high‑intensity statin (≥55 mg/dL with ASCVD or >70 mg/dL without ASCVD) and documentation of statin therapy or intolerance.
- Include genetic confirmation or phenotype evidence for HoFH when applicable.
Prevymis — PA for CMV prophylaxis in defined transplant settings
Prevymis PA is required for CMV prophylaxis in CMV‑seropositive HSCT recipients or high‑risk kidney transplant recipients (D+/R‑); include transplant serostatus and transplant type in the request.
- Attach transplant records and CMV serostatus (donor/recipient) documentation.
- Coverage duration noted as one year.
Jubbonti / Stoboclo — PA and bisphosphonate trial required
Jubbonti and Stoboclo require prior authorization and Part B versus Part D review; approval requires trial of an oral bisphosphonate or, if intolerant, an IV bisphosphonate (documentation of intolerance or inability to receive both is acceptable).
- Provide records documenting the oral bisphosphonate trial (or IV bisphosphonate if oral is intolerable) and any Part B/Part D status information.
- Coverage duration for Jubbonti/Stoboclo is listed as 3 years.
Eltrombopag Olamine — baseline platelet thresholds and prior therapies required
Eltrombopag Olamine PA requires baseline platelet counts and indication-specific thresholds: <30,000/mcL for persistent/chronic ITP, <75,000/mcL for HCV-associated thrombocytopenia, and <30,000/mcL for severe aplastic anemia; document prior therapies for ITP (corticosteroids, IVIG, or splenectomy).
- Include baseline platelet count and records of prior ITP therapies or reasons for intolerance.
- Coverage duration noted as 1 year.
Retevmo — genetic test confirmation and prior therapy documentation required
Retevmo PA requires documented RET gene fusion/mutation detected by an FDA‑approved test for indicated uses; some indications also require prior systemic therapy or trial and failure of radioactive iodine when appropriate.
- Attach the FDA‑approved test report confirming RET fusion/mutation.
- For thyroid or other indications, include documentation of prior radioactive iodine or systemic therapy as specified.
Lenalidomide — PA requires oncologist involvement and prior therapy documentation
Lenalidomide prior authorization requires prescribing by or in consultation with an oncologist/hematologist and documentation of indication‑specific prior therapy or combination use (e.g., use with dexamethasone in multiple myeloma).
- Attach oncology consult notes and documentation of required combination regimens or prior therapy lines per the indication.
- Coverage duration commonly one year.
Rezdiffra — semaglutide trial required and renewal documentation
Rezdiffra (for NASH/MASH) requires prior authorization with a documented trial of semaglutide prior to approval; renewal requires no progression to cirrhosis and evidence of improvement or stabilization by imaging or noninvasive assessment.
- Provide FibroScan or other imaging-based noninvasive assessment verifying F2–F3 fibrosis and documentation of a semaglutide trial.
- For renewal, submit evidence of fibrosis improvement ≥1 stage or NASH resolution, or other documented clinical benefit.
Rezurock — PA requires failure of ≥2 prior systemic therapies
Rezurock prior authorization for chronic GVHD (age ≥12) requires documented trial and failure of at least two prior lines of systemic therapy before approval.
- Provide prior systemic therapy records including agents, durations, and reason for failure or intolerance.
- Coverage duration listed as one year.
Rinvoq — PA requires prerequisite trials and reauthorization response
Rinvoq (including Rinvoq Lq) prior authorization requires indication‑specific diagnostic criteria and prerequisite trials (e.g., DMARDs, NSAIDs, TNF inhibitors where specified); reauthorization requires documentation of positive clinical response and avoidance of prohibited combinations (potent immunosuppressants or another biologic for same condition).
- Include records of prior conventional therapy trials and clinical response measures when requesting renewal.
- Do not combine Rinvoq with potent immunosuppressants (azathioprine, cyclosporine) or another biologic/targeted DMARD—document current/concurrent therapies.
Rivfloza — genetic confirmation required; transplant and combination exclusions
Rivfloza prior authorization requires genetic confirmation of primary hyperoxaluria type 1 (AGXT mutation); coverage is not provided for patients with a history of kidney or liver transplant or for combination use with OXLUMO.
- Attach genetic testing confirming AGXT mutation.
- Do not request coverage for patients with prior kidney or liver transplant or for concurrent OXLUMO; such requests will be excluded.
Rybrevant — prior platinum chemotherapy and mutation documentation required
Rybrevant PA requires disease progression on platinum‑based chemotherapy for NSCLC with EGFR exon 20 insertions; other EGFR mutation contexts require the specified combination chemotherapy or prior EGFR TKI per indication.
- Provide documentation of platinum‑based chemotherapy and disease progression for the EGFR exon 20 indication.
- Include molecular testing for EGFR exon 20 insertion where applicable.
Rydapt — PA requires combination with standard induction/consolidation
Rydapt prior authorization for newly diagnosed FLT3‑mutant AML requires combination with standard cytarabine and daunorubicin induction and cytarabine consolidation; include treatment plan documentation showing combination use.
- Attach oncology treatment records confirming induction and consolidation regimens.
- Coverage duration typically one year.
Tolvaptan — liver disease exclusion and prerequisite therapies required
Tolvaptan PA requires documentation that the patient does not have underlying liver disease and a trial of at least two of: furosemide, demeclocycline, or fluid restriction; coverage duration is 1 month.
- Provide liver evaluation/lab evidence ruling out underlying liver disease and records of trials of the specified alternatives.
- Note the limited 1‑month authorization duration for initial coverage.
Secuado — PA requires trial of asenapine sublingual or documentation of inability to use oral/ODT
Secuado for schizophrenia requires prior authorization and documentation of trial of sublingual asenapine or a note documenting inability to use oral/ODT formulations; coverage duration is listed as lifetime.
- Submit records documenting the asenapine sublingual trial or documentation of swallowing/ODT intolerance.
- Coverage duration is lifetime when criteria are met.
Scemblix — PA with one‑year duration (no prerequisite Part D drug)
Scemblix requires prior authorization with a one‑year coverage duration; no prerequisite Part D drug is required for initiation.
- Include diagnosis and prescriber details per the product entry when requesting PA.
- Reauthorization follows the standard requirement for documentation of clinical response if listed.
Simponi — PA with two‑agent prior‑trial requirement and reauthorization response
Simponi requires prior authorization (1 year); for many indications approval requires trials of two listed alternative agents and reauthorization requires documentation of positive clinical response.
- For RA, PsA, AS and UC, provide documentation of the two required alternative agent trials as listed in the product criteria.
- Include reauthorization evidence of clinical improvement for continued coverage.
Skyrizi / Sohonos — PA, combination exclusions, and Sohonos genetic confirmation
Skyrizi and Sohonos require prior authorization with a 1‑year duration; Skyrizi cannot be used in combination with another biologic/targeted DMARD for the same condition and reauthorization requires documentation of positive clinical response; Sohonos for FOP requires genetic confirmation of an ACVR1 mutation.
- For Skyrizi, include prior‑therapy trials per indication and confirm no concurrent biologic/targeted DMARD use.
- For Sohonos, attach genetic test confirming ACVR1 mutation and documentation of clinical indication.
Stivarga — PA requires specified prior oncology therapies
Stivarga prior authorization (one year) requires documentation of prior therapies for CRC, GIST, and HCC as specified (e.g., prior fluoropyrimidine-, oxaliplatin-, irinotecan‑based chemo and anti‑VEGF/anti‑EGFR where applicable).
- Attach records showing the required prior chemotherapy regimens and targeted therapy trials before requesting Stivarga.
- Coverage duration noted as one year.
Sunosi — trial of armodafinil required before approval
Sunosi prior authorization requires a documented trial of armodafinil prior to coverage.
- Provide clinical documentation of armodafinil trial and reason for failure or intolerance if Sunosi is requested.
- Coverage duration listed as one year.
Tafinlar — PA requires prior trials/combination and liquid‑form rationale
Tafinlar (including liquid) requires prior authorization (1 year) and, for many BRAF‑mutant indications, trial of vemurafenib + cobimetinib or combination use with trametinib as specified; liquid formulation is covered only if patient cannot swallow capsules.
- Include mutation testing, prior therapy trials, and documentation that the capsule formulation cannot be used when requesting liquid.
- Ensure combination therapy documentation is attached when required.
Tagrisso — PA requires EGFR mutation documentation and prior therapy per indication
Tagrisso prior authorization (1 year) requires documentation of the specific EGFR mutation for the indicated NSCLC use (exon 19 deletion or exon 21 L858R, or T790M where applicable) and prior therapy details per indication.
- Attach molecular testing reports confirming the EGFR mutation and records documenting prior EGFR TKI exposure or platinum‑based therapy where required.
- Follow the indication‑specific prior‑therapy rules in the product entry.
Talzenna — PA requires combination with enzalutamide
Talzenna for mCRPC requires use in combination with enzalutamide; document concomitant therapy per the product criteria.
- Provide oncology treatment plan showing combination use with enzalutamide.
- Coverage duration is one year.
Erlotinib — PA requires line‑of‑therapy and combination documentation
Erlotinib prior authorization for NSCLC requires concurrent treatment sequencing per line of therapy and, for pancreatic cancer, use in combination with gemcitabine; prescriber should be an oncologist.
- Include documentation of line of therapy and concurrent chemotherapy (gemcitabine) where applicable.
- Ensure the prescriber is an oncologist or consultation is documented.
Step Therapy Rules & Tables
| Example products | Step requirement |
|---|---|
| Requires trial of one high-intensity statin unless statin intolerance or contraindication is documented prior to coverage. | |
| Requires trial of at least two generic triptans prior to coverage unless contraindicated or not tolerated. | |
| Requires trial of two generic anticonvulsant alternatives prior to coverage. |
| Product / class | Requirement |
|---|---|
| Trial of at least two generic triptans (e.g., sumatriptan and rizatriptan) required prior to coverage unless contraindicated, not tolerated, or clinically inappropriate. |
| Product | Step requirement |
|---|---|
| Requires trial and failure or contraindication to sildenafil prior to coverage; titration kits require trial/failure or contraindication to inhaled treprostinil and sildenafil. |
| Products | Step requirement |
|---|---|
| Require trial of an oral bisphosphonate or, if intolerant, an IV bisphosphonate prior to coverage; coverage also provided if unable to be treated with both; BMD documentation (T-score ≤ -2.5) required. |
| Product | Step requirement |
|---|---|
| Requires documentation of NASH/MASH with advanced liver fibrosis (F2–F3) and a prior trial of semaglutide before approval; renewal criteria specified. |
| Product | Step requirement |
|---|---|
| Coverage requires a trial of Betaseron prior to Rebif. |
| Product | Step requirement |
|---|---|
| Requires trial and failure of at least two prior lines of systemic therapy for chronic GVHD (age ≥12) prior to coverage. |
| Context | Summary step requirement |
|---|---|
| Multiple products require trials of specified alternative biologics or targeted agents (often two) prior to coverage; combination use with another biologic/targeted DMARD for the same condition is disallowed. |
| Product | Step requirement (RA/JIA examples) |
|---|---|
| For RA: requires trial of two of Enbrel, adalimumab biosimilars, Rinvoq, Xeljanz/XR, Orencia; for polyarticular JIA similar multi-agent trial requirement; reauthorization requires documentation of positive clinical response. |
| Product | Step requirement |
|---|---|
| Requires trials of Jubbonti or Stoboclo and an oral bisphosphonate (or IV bisphosphonate if intolerant) before coverage; BMD documentation required (T-score ≤ -2.5). |
| Product / context | Requirement |
|---|---|
| Must be used in patients with chronic heart failure NYHA class II–IV with LVEF <45% plus either prior hospitalization for heart failure within prior 6 months or outpatient IV diuretic within prior 3 months; must be taken with at least two guideline-directed therapies unless contraindicated. |
| Products (examples) | Prerequisite Part D / step requirement |
|---|---|
| Requires trial of generic dapagliflozin prior to Farxiga or Jardiance, except Jardiance when used to reduce cardiovascular death in qualifying adults (Jardiance exception). | |
| Requires background use of at least two guideline-directed heart failure therapies; prior therapy documentation required. |
| Product | Prerequisite Part D example |
|---|---|
| Subject to Part B versus Part D review; requires trial of an oral bisphosphonate or IV bisphosphonate if intolerant prior to coverage. | |
| Requires trial of semaglutide prior to approval for NASH/MASH; prerequisite Part D drug required. |
| Product / group | Step requirement |
|---|---|
| Requires trial of Betaseron prior to Rebif. | |
| Requires trial or intolerance to at least 2 generic anticonvulsants prior to coverage (lifetime duration). | |
| Requires trial of at least 2 specified generic antidepressants prior to coverage (lifetime duration). |
| Product | Step requirement |
|---|---|
| Requires trial or intolerance to at least 2 generic anticonvulsants prior to coverage; coverage duration lifetime. | |
| Requires trial of at least 2 listed generic antidepressants prior to coverage; coverage duration lifetime. | |
| Require trial of at least one listed generic antipsychotic prior to coverage; coverage duration lifetime. |
| Product | Step requirement |
|---|---|
| Requires prior trial of once-monthly paliperidone palmitate ER injectable for ≥4 months OR every-three-month paliperidone palmitate ER injectable for at least one 3-month cycle before coverage. | |
| Require trial of oral paliperidone or oral risperidone prior to coverage; coverage duration lifetime. |
| Class / product | Step requirement |
|---|---|
| Require documented trial of at least 2 specified generic antidepressants prior to coverage. | |
| Require trial of at least one listed generic antipsychotic prior to coverage. | |
| Requires trial or intolerance to at least 2 generic anticonvulsants prior to coverage. |
| Product / context | Step requirement |
|---|---|
| Requires prior trial of Betaseron before Rebif (step therapy). | |
| Requires trials of specified alternative agents (e.g., Enbrel, adalimumab biosimilars, Rinvoq, Xeljanz/XR, Orencia) depending on indication before coverage; reauthorization requires documentation of positive clinical response. | |
| Often require trial of specified conventional therapies (DMARDs, NSAIDs, TNF inhibitors) or specified alternative biologics prior to approval. |
| Product | Step requirement / exception |
|---|---|
| Requires prior use of specified paliperidone palmitate injectable regimens (see Invega Hafyera entry) before coverage. | |
| Requires trial of generic dapagliflozin before Farxiga or Jardiance; exception: Jardiance when used to reduce risk of cardiovascular death in adults with T2DM and established CVD is exempt from step therapy. |
| Product / class | Step requirement |
|---|---|
| Require trial of generic dapagliflozin prior to Farxiga or Jardiance, except Jardiance for reduction of cardiovascular death in qualifying adults (no step therapy). | |
| Require trial of one high-intensity statin prior to coverage unless documented statin intolerance exists. |
Coding and Numeric Thresholds
| Oxcarbazepine Er TB24 300MG | Product listing from formulary |
| Oxcarbazepine Er TB24 600MG | Product listing from formulary |
| Desvenlafaxine Er TB24 100MG | Product listing from formulary |
| Desvenlafaxine Er TB24 50MG | Product listing from formulary |
| Exxua | Product listing from formulary |
| Exxua Titration Pack | Product listing from formulary |
| Trintellix | Product listing from formulary |
| Caplyta | Product listing from formulary |
| Rexulti | Product listing from formulary |
| Vraylar CAPS | Product listing from formulary |
| Zyprexa Relprevv | Product listing from formulary |
| Apidra | Product listing from formulary |
| Apidra Solostar | Product listing from formulary |
| Aristada | Product listing from formulary |
| Aristada Initio | Product listing from formulary |
| Alcohol Prep Pads PADS 70% | Supply listing from formulary |
| Curity Gauze Pads 2"x2" 12 Ply | Supply listing from formulary |
| Invega Hafyera | Product listing from formulary |
| Invega Sustenna | Product listing from formulary |
| Invega Trinza | Product listing from formulary |
Definitions & Terms
Site-of-Care & Billing Determinations
Background and Policy Basis
The formulary prior authorization and step-therapy criteria are developed from medical evidence and the Blues’ Pharmacy & Therapeutics Committee recommendations. Prior authorization is required for many listed drugs and, unless otherwise specified, authorizations are generally issued for 1 year. Clinical requirements commonly include specific diagnoses, prerequisite trials of alternative or generic therapies, lab or diagnostic test documentation, and restrictions on prohibited combinations (for example, biologic overlap and certain contraindicated combinations).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.