Formulary step therapy and prior authorization rules for selected drugs
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Lists step therapy and prior authorization criteria for specific formulary products and applies to Blue Cross Blue Shield - South Carolina members and providers managing these drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Diclofenac Sodium GEL 3% Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Antidepressants Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Atypical Antipsychotics Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Invega Hafyera Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Relistor Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Rytary Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
Zonisade Initial Therapy
Covered when ALL of the following are met:
Formulary ID: 26216, Version: 11
This section is an index/listing of drug names and related entries and does not contain coverage criteria or specific exclusions. Use the index entries to locate the individual drug policy pages for detailed coverage rules, prior authorization, step therapy, and documentation requirements.
The content shown here is an index only and does not include any medical necessity, coverage, or exclusion criteria. Refer to the referenced policy pages (by drug name and page number) for the specific coverage rules and requirements.
This fragment is an index listing (drug names and titration pack entries) and does not present coverage rules, clinical criteria, or exclusion statements. Consult the full policy pages for each listed product to find applicable coverage criteria.
The section shown is an index of drugs and titration packs and does not provide coverage criteria or exclusions. Use the index references to navigate to the individual drug policies where coverage rules and authorization details are specified.
Not applicable in terms of coverage criteria — this portion is index material only. It lists drugs and score references but contains no medical necessity or exclusion language.
This index fragment does not include coverage statements or exclusion rules. It serves solely as a table-of-contents style listing to locate detailed policy content elsewhere in the document.
Provider Actions & Prior Authorization
Prior authorization requires trial of topical fluorouracil or imiquimod
Trial of either topical fluorouracil or topical imiquimod is required before prior authorization will be granted for Diclofenac Sodium GEL 3%.
- Required trial: topical fluorouracil OR topical imiquimod
Prior authorization: trial of two generics required (continuation approved)
For listed antidepressant products, prior authorization for new starts requires documentation of trials of two generic agents from the specified list; continuation of prior therapy is approved.
- Required trial: two generics from bupropion, mirtazapine, citalopram (tablet or solution), desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine hydrochloride
- Continuation of prior therapy is approved
Prior authorization: trial of two generic atypical antipsychotics required
Prior authorization for Fanapt and related titration packs requires documentation of trials of two oral generic formulary atypical antipsychotic agents from the listed agents; continuation of prior therapy is approved.
- Required trial: two oral generic atypical antipsychotics from asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
- Continuation of prior therapy is approved
Prior authorization: trial of Invega Sustenna or Trinza required for new starts
For new starts of Invega Hafyera, prior authorization requires a trial of Invega Sustenna or Invega Trinza; members already receiving Invega Hafyera may be approved for continuation of prior therapy.
- Required trial for new starts: Invega Sustenna OR Invega Trinza
- Step applies to new starts only; continuation is approved
Prior authorization: trial of specified laxatives required
Prior authorization for Relistor requires documentation of a trial of one of the listed laxatives before approval will be granted.
- Required trial: lubiprostone, Constulose, Enulose, Generlac, OR lactulose
Prior authorization: trial of generic carbidopa/levodopa required
Prior authorization for Rytary requires documentation of a trial of a generic carbidopa/levodopa containing formulation prior to approval.
- Required trial: one generic carbidopa/levodopa containing formulation
Prior authorization: trial of generic zonisamide capsule required for new starts
For new starts of Zonisade, prior authorization requires a documented trial of a generic zonisamide capsule; members already receiving therapy may be approved for continuation.
- Required trial for new starts: generic zonisamide capsule
- Step applies to new starts only; continuation is approved
Index section — no prior authorization requirements listed
These index pages list drugs and topics but do not state prior authorization requirements; use the individual drug policy pages for authorization details.
- Index lists drug names and score/page references only
- No prior authorization information provided here
Index — no prior authorization information
This index fragment is a listing of drugs and does not specify any prior authorization requirements.
- Index-only content; no PA rules
Index: refer to individual drug policy pages for prior authorization
The index does not specify prior authorization requirements; refer to the individual drug policy pages indicated by the index references for authorization rules.
- Index entries point to drug policy pages for PA details
Prior authorization not specified in this index fragment
This index fragment does not state prior authorization requirements and contains only listing content.
- No PA instructions on this index page
Index — prior authorization not specified
This index section lists drugs but does not specify any prior authorization requirements.
- Index-only content; no PA details provided
Prior authorization not specified in index (none listed)
No prior authorization requirements are specified in this index section; it is an index/listing only.
- Index entries only; consult drug pages for PA rules
Index — no prior authorization info
This index fragment is an index only and does not state prior authorization requirements.
- Index-only fragment; no authorization guidance
Index — no PA stated
This index section is a listing only and does not state any prior authorization requirements.
- Index-only; no PA requirements included
Prior Authorization (none specified in this index fragment)
No prior authorization requirements are specified in this index fragment; it contains listing content only.
- Consult individual drug pages for PA rules
Index — no PA details
These index pages list drug names and page references but do not provide prior authorization details; consult the indicated policy pages for authorization instructions.
- Index entries only; no PA details
Prior authorization not specified in index (titration packs listed)
This index fragment does not specify prior authorization requirements; it lists drug names and titration packs only.
- Index-only fragment; refer to drug pages for PA
Index listing — no PA indicated
This index segment is a listing only and does not state prior authorization requirements.
- Index content; no PA rules
Prior authorization not listed on index pages
No prior authorization requirements are specified on these index pages; they are listings only.
- Index-only; consult policy pages for PA
Prior authorization not specified in index
This index section does not contain prior authorization requirements; it lists drugs and references only.
- Index entries only; no PA requirements present
Step therapy for Invega Hafyera: trial of Sustenna or Trinza for new starts
Step therapy for Invega Hafyera applies to new starts only and requires a trial of Invega Sustenna or Invega Trinza.
- Step applies to new starts only
- Required trial: Invega Sustenna OR Invega Trinza
Step therapy for Zonisade: trial of generic zonisamide capsule for new starts
Step therapy for Zonisade applies to new starts only and requires a trial of a generic zonisamide capsule.
- Step applies to new starts only
- Required trial: generic zonisamide capsule
No step therapy rules in index content
These index pages do not include any step therapy rules; they are listings used to locate policy details.
- Index-only content; no step therapy rules present
No step therapy requirements in index fragment
No step therapy requirements appear in this index fragment; consult the individual drug policy pages for any step therapy rules.
- Index-only fragment; no step therapy details
No step therapy rules presented in these index pages
The index pages do not present step therapy rules; they only list drug names and references.
- Index-only; no step therapy rules presented
No step therapy information present in this fragment
No step therapy information is present in this index fragment.
- Consult specific drug pages for step therapy
No step therapy rules included in this index section
No step therapy rules are included in this index section; use the drug policy pages for step therapy requirements.
- Index-only content; no step therapy rules
No step therapy rules present in this index section
No step therapy rules are present in this index section.
- Index-only; no step therapy information
No step therapy rules in index fragment
This index fragment does not include step therapy rules.
No step therapy rules in this index fragment
No step therapy rules are included in this index fragment.
No step therapy rules included in this index fragment
This index fragment does not contain step therapy rules.
No step therapy rules appear in index entries
No step therapy rules appear in the index entries; consult the individual drug pages for any step therapy requirements.
Provider actions — index fragment (empty summary)
This index fragment is a listing only and does not provide provider action guidance.
Provider actions — index fragment (empty summary)
This index fragment is an index listing and contains no provider authorization or documentation requirements.
Provider actions — index fragment (empty summary)
This index fragment does not present step therapy rules or provider actions.
No step therapy rules (index fragment)
No step therapy rules are present in this index fragment.
Documentation: prior topical therapy required for Diclofenac
Documentation of prior topical therapy (topical fluorouracil or topical imiquimod) is required when requesting prior authorization for Diclofenac Sodium GEL 3%.
- Provide clinical documentation showing trial of topical fluorouracil OR topical imiquimod
Documentation: record trials of two generics for antidepressants (continuation accepted)
Clinical records must document trials of two generics from the specified antidepressant list for new starts; documentation of prior therapy is acceptable for continuation requests.
- Document trials of two generics (see antidepressant list)
- For continuation, provide evidence of prior therapy
Documentation: record trials of two generic atypical antipsychotics
Requests for Fanapt or its titration packs must include clinical documentation of trials of two oral generic formulary atypical antipsychotics from the listed agents, or evidence of prior therapy for continuation.
- Document trials of two generics from asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
- For continuation, provide evidence of prior therapy
Documentation: trial of Sustenna or Trinza required for Invega Hafyera new starts
For new Invega Hafyera starts, include documentation showing trial of Invega Sustenna or Invega Trinza; for continuation, provide evidence of prior therapy.
- Document trial of Invega Sustenna OR Invega Trinza for new starts
- For continuation, provide evidence of prior therapy
Documentation: trial of listed laxatives required for Relistor
Requests for Relistor must include documentation of a trial of one of the listed laxatives prior to approval.
- Document trial of lubiprostone, Constulose, Enulose, Generlac, OR lactulose
Documentation: trial of generic carbidopa/levodopa required for Rytary
Documentation of a trial of a generic carbidopa/levodopa containing formulation is required for Rytary prior authorization requests; documentation of prior therapy is acceptable for continuation.
- Provide clinical documentation of trial of a generic carbidopa/levodopa formulation
- For continuation, supply evidence of prior therapy
Documentation: trial of generic zonisamide capsule required for Zonisade new starts
For new starts of Zonisade, provide documentation of a trial of a generic zonisamide capsule; for continuation, evidence of prior therapy is acceptable.
- Document trial of generic zonisamide capsule for new starts
- For continuation, provide evidence of prior therapy
Index entries only — no documentation requirements here
Index entries list drug names and section markers for locating policy content; these index fragments do not specify documentation or submission requirements.
- Index-only content; no documentation instructions provided
Index pages — no documentation or provider action requirements
These index pages do not include documentation or provider action requirements; consult the individual drug policy pages for submission instructions.
- Index-only; no documentation requirements
Index points to policy pages — no submission instructions here
Index listings point to where full policy content can be found but do not include documentation or submission requirements in these fragments.
- Refer to the indicated drug pages for documentation requirements
Index only — no documentation requirements
This index fragment is an index only and does not contain documentation requirements.
Index fragment — no documentation requirements
Index listings in this fragment do not contain documentation requirements.
Index pages — no documentation requirements
These index pages do not include documentation requirements for provider submissions.
Provider actions — index fragment (empty summary)
This index fragment provides no provider action or documentation requirements.
Denial risk: missing documentation for Diclofenac
Failure to document the required prior topical therapy for Diclofenac Sodium GEL 3% may result in denial of the prior authorization request.
- Denial risk: no documentation of trial of topical fluorouracil or topical imiquimod
Denial risk: missing generic trials for antidepressants
For listed antidepressant products, lack of documented trials of two generics from the specified list may lead to non-approval for new starts.
- Denial risk: no record of two generic antidepressant trials for new starts
Denial risk: missing atypical antipsychotic trials
For Fanapt and related titration packs, absence of documentation showing trials of two oral generic formulary atypical antipsychotics from the specified list may lead to denial for new starts.
- Denial risk: missing trials of two generic atypical antipsychotics
Denial risk: missing Sustenna/Trinza trial for Invega Hafyera
For Invega Hafyera new starts, failure to document a trial of Invega Sustenna or Invega Trinza may result in non-approval.
- Denial risk: no trial of Invega Sustenna or Invega Trinza documented for new starts
Denial risk: missing laxative trials for Relistor
For Relistor, absence of documentation of a trial of one of the listed laxatives (lubiprostone, Constulose, Enulose, Generlac, or lactulose) may trigger denial.
- Denial risk: no trial of listed laxatives documented
Denial risk: missing carbidopa/levodopa trial for Rytary
For Rytary, failure to document a trial of a generic carbidopa/levodopa formulation may lead to non-approval.
- Denial risk: missing trial of generic carbidopa/levodopa
Denial risk: missing zonisamide trial for Zonisade
For Zonisade, lack of documentation showing a trial of a generic zonisamide capsule for new starts may result in denial.
- Denial risk: no trial of generic zonisamide capsule documented for new starts
Index-only — no authorization or denial criteria here
These index fragments do not state authorization triggers or denial criteria themselves; consult the individual drug policy pages for those details.
Index pages — no documentation or provider action requirements
No documentation or provider action requirements are included in these index pages; providers should refer to the specific drug policy pages for instructions.
Index — no documentation or submission requirements provided
Index entries point to policy locations but do not contain documentation or submission requirements in these fragments.
Index only — no documentation requirements provided
This index listing does not include documentation requirements; consult each drug's policy page for required documentation.
Index — no documentation requirements in this fragment
This index fragment is an index only and does not contain provider authorization or documentation requirements.
Index only — no documentation requirements
This section is an index only and does not include documentation requirements for provider submissions.
Index listing — no provider authorization or documentation requirements
This fragment is an index listing and does not contain provider authorization or documentation requirements.
Index lists Fanapt titration packs — no documentation guidance here
Index listing of Fanapt Titration Pack A and B is provided without guidance on required documentation; consult the Fanapt policy page for submission requirements.
- Index lists Fanapt Titration Pack A/B but provides no documentation guidance
Initial Therapy Criteria
Diclofenac Sodium GEL 3% Initial Therapy
Diclofenac Sodium GEL 3% initial therapy — single top-level criterion:
Formulary ID: 26216, Version: 11
Antidepressants Initial Therapy
Antidepressants initial therapy — single top-level criterion:
Formulary ID: 26216, Version: 11
Atypical Antipsychotics Initial Therapy
Atypical antipsychotics initial therapy — single top-level criterion:
Formulary ID: 26216, Version: 11
Continuation of Therapy
Continuation Therapy
Continuation of prior therapy is generally approved for the listed products when the member is already receiving the therapy.
Formulary ID: 26216, Version: 11
Step Therapy Rules
| Product | Step requirement (new starts only) | Continuation of prior therapy |
|---|---|---|
| Invega Hafyera | Trial of one of the following: Invega Sustenna or Invega Trinza. (Step applies to new starts only) | Approve for continuation of prior therapy. |
| Zonisade | Trial of generic zonisamide capsule. (Step applies to new starts only) | Approve for continuation of prior therapy. |
Background
This extract is an index/table of contents fragment listing drug names and titration packs. It does not provide clinical background, coverage criteria, or guidance — consult the individual drug policy pages for clinical context and authorization requirements.
Definitions & Index Entries
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