CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Step Therapy Programs for Members on the Basic Drug List or Enhanced Drug List

Defines step therapy category groupings and preferred step sequencing for members on the Basic or Enhanced Drug List for Blue Cross Blue Shield - Oklahoma; affects providers and pharmacists requesting coverage for listed prescription drugs.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyStep Therapy Programs for Members on the Basic Drug List or Enhanced Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInitiate preferred Step 1 agents before prescribing Step 2 agents unless an approved exception is documented.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecategories

two-tierstep tiers

repeatednon-preferred strips

member linesupport line

Coverage Criteria Overview

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Provider Actions & Prior Steps

Step Therapy

Step therapy required for listed drug categories

Step therapy is required for many drug categories. Drugs are organized into Step 1 (preferred first-line) and Step 2 (requires trial and failure of Step 1 or an approved exception). Providers should follow the specified sequencing when prescribing.

Step 1 = preferred medications to try first
Step 2 = medications covered after Step 1 failure or prior authorization/exception
Examples: Atypical antipsychotics, SGLT inhibitors, oral inhalers, ophthalmic prostaglandins and other categories follow step sequencing

Prior Authorization

Provider actions — sequencing and documentation

When submitting requests, indicate prior trial(s) of Step 1 agents and supporting documentation of inadequate response, intolerance, or contraindication to meet Step 2 coverage requirements. Providers may request an exception when clinically appropriate.

Document dates and therapies tried, doses, and reasons for discontinuation
Attach clinical notes or lab results when available
Requests for Step 2 coverage without documented Step 1 failure may be denied

Denial Risk

Non-preferred glucose test strips denial risk

Requests for non-preferred brand glucose test strips and disks may be denied when a preferred brand is available. If a patient has a medical need for a specific non-preferred brand, submit clinical justification and documentation to support an exception.

Non-preferred glucose test strips and disks are subject to denial risk if preferred alternatives are available
Provide clinical rationale (e.g., device compatibility, documented allergy/sensitivity) when requesting non-preferred strips

Note

Contact information for questions

If you have questions about step therapy requirements, exceptions, or prior authorization, call the number listed on the member's ID card.

Use the contact number on the member ID card for benefits, eligibility, and prior authorization inquiries

Initial (Step 1) Therapy

Step 1 (Initial Therapy)

Initial preferred agents (Step 1) per category.

Examples of Step 1: Lists first-line/preferred agents for categories (examples include: Insomnia — Ambien, Ambien CR, Belsomra, Dayvigo, Edluar; Ophthalmic Prostaglandins — Idose, Iyuzeh, Lumigan, Travatan Z; SGLT Inhibitors — Brenzavvy/Bexagliflozin, Inpefa, Invokana, Invokamet, Invokamet XR; Topical NSAIDs — Flector, Licart; Phosphate Binder — Auryxia, Fosrenol/lanthanum carbonate, Renagel; Colony Stimulating Factors — Fylnetra, Granix, Neulasta, Neupogen, Nypozi; Specialty Therapy Step — Specialty Therapy Step; Kerendia — Kerendia; Infertility — Chorionic Gonadotropin, Gonal F).

Providers should initiate Step 1 agents before Step 2 agents unless an exception is documented or prior authorization for Step 2 is approved.

Step Sequencing and Step 2 Agents

Step	Category / Example Step 1 agents	Example Step 2 agents
Step 1
Ambien; Ambien CR; Belsomra; Dayvigo; Edluar
Lunesta; Quviviq; Rozerem; Silenor; Zolpidem
Idose; Iyuzeh; Lumigan; Travatan Z
Vyzulta; Xalatan; Xelpros
Brenzavvy/Bexagliflozin; Inpefa; Invokana; Invokamet; Invokamet XR
Qtern; Segluromet; Steglatro; Steglujan
Auryxia; Fosrenol/lanthanum carbonate; Renagel
Renvela hydrochloride; Velphoro
Flector; Licart
Pennsaid/diclofenac 2% solution
Fylnetra; Granix; Neulasta; Neupogen; Nypozi
Releuko; Rolvedon; Stimufend; Udenyca; Ziextenzo
Specialty Therapy Step (Step 1)
Specialty Therapy Step (Step 2)

Key Definitions

Step 1 / Step 2 definitions and requirements

Step 1 (preferred agents)Indicates the preferred agent(s) within a step therapy category; members should initiate therapy with Step 1 agents (e.g., Insomnia Step 1 = Ambien, Ambien CR; Ophthalmic Prostaglandins Step 1 = Idose, Iyuzeh, Lumigan, Travatan Z).

Step 2 (alternative/non-preferred agents)Indicates alternative or non-preferred agents that require prior step failure or an approved exception before coverage (e.g., Insomnia Step 2 = Lunesta, Quviviq, Rozerem, Silenor, Zolpidem; Ophthalmic Prostaglandins Step 2 = Vyzulta, Xalatan, Xelpros).

Sequencing requirementMembers must follow the step sequence for the applicable drug category—use Step 1 agent before Step 2 agent—unless an approved exception applies.

Examples across categoriesStep 1 and Step 2 sequencing is applied across multiple therapeutic categories such as SGLT Inhibitors, Oral Inhalers, Phosphate Binders, Topical NSAIDs, Colony Stimulating Factors, and Specialty Therapy.

Exception process impliedCoverage of Step 2 agents is contingent on documented failure, intolerance, or approved exception to Step 1 agents per the step therapy program.

Background

This policy provides step therapy sequencing across multiple therapeutic categories for members on the Basic or Enhanced Drug List. Drugs are organized into categories with a preferred Step 1 agent and one or more Step 2 alternatives; members are expected to follow the listed step sequence before coverage for Step 2 agents is approved. For questions regarding the programs or member-specific coverage, contact the number on the member’s ID card. The programs and listed agents may change over time and additional drugs may be added, so providers should confirm current category placement before initiating non-preferred therapies.