Drug coverage and step therapy rules (partial index)
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Portion of the payer's pharmacy coverage document listing affected products and step/step-therapy criteria for selected specialty and non-specialty drugs; intended for providers and pharmacy staff applying prior authorization and step edits for Blue Cross Blue Shield - South Carolina members.
No material clinical or coverage changes in this revision.
Coverage Criteria (Index Excerpt)
Antidepressant step requirement
Antidepressant products (Auvelity, Emsam, Exxua and related items)
Approve for continuation of prior therapy.
Atypical antipsychotic step requirement
Atypical antipsychotic products (Fanapt and titration packs)
Approve for continuation of prior therapy.
Invega Hafyera initial therapy
Invega Hafyera
Step applies to new starts only. Approve for continuation of prior therapy.
Relistor initial therapy
Relistor
Rytary initial therapy
Rytary
Zonisade initial therapy
Zonisade
Step applies to new starts only. Approve for continuation of prior therapy.
Actinic keratosis topical therapy requirement
Actinic keratosis topical therapy (Diclofenac Sodium GEL 3%)
No coverage or exclusion criteria are present in this index fragment. The content in this section is navigational (index) material listing drug names and topic scores rather than clinical coverage rules.
No coverage criteria or exclusions are presented on these index pages. The repeated lines reference drug names and page markers (for example, Emsam and Exxua) without stating coverage decisions or exclusion language.
No coverage criteria or exclusions are provided in these index pages. The text is an index listing (drug names and titration packs) and does not include medical necessity or coverage statements.
No coverage, exclusion, or medical necessity statements are present in this index fragment. The repeated entries (drug names and titration pack references) serve only as navigational pointers to other sections of the policy.
No explicit coverage exclusions are present in this fragment. The content consists of repeated index entries for a specific drug (Exxua) and its titration pack without coverage or exclusion language.
No NMN (not medically necessary) statements are present in this section. The material shown is part of the index and does not include determinations of medical necessity.
No 'not medically necessary' statements are present in this fragment. The content repeats index lines for drug names and titration packs and contains no NMN language.
Provider Actions and Documentation Requirements
Invega Hafyera step requirement
Prior authorization for Invega Hafyera (new starts) requires documentation of a trial of either Invega Sustenna or Invega Trinza. Approvals may be granted to continue existing Invega Hafyera therapy without repeating the step requirement.
- Step applies to new starts only
- Approve for continuation of prior therapy
Zonisade step requirement
Prior authorization for Zonisade (new starts) requires documentation of a trial of a generic zonisamide capsule. Continuation of prior therapy is allowed.
- Step applies to new starts only
- Approve for continuation of prior therapy
Index — no PA details
This section is an index listing drug names and topic references. The fragments shown do not specify prior authorization details, step-therapy rules, or documentation requirements — consult the full policy sections referenced by the index for complete PA rules.
- Index contains only drug names and score/page references
- No prior authorization requirements are listed in these index fragments
Prior authorization not specified in this fragment
Prior authorization requirements are not specified in many of the index fragments included here; these pages function as navigational content only and do not contain PA decision criteria.
- Prior authorization not specified in this fragment
- This fragment is an index and does not contain documentation requirements for authorization
Index — no PA rules / listing
The index fragments do not list prior authorization rules. Where only index content appears, no PA rules, step therapy details, or denial triggers are provided.
- Index — no PA rules
- Index listing — no PA guidance
- Prior authorization not listed
Antidepressant step requirement — documentation
Document trials of two specified oral generic antidepressant agents prior to approval of certain branded antidepressant products (examples include bupropion, mirtazapine, citalopram, desvenlafaxine ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine HCl). Approval may be limited to continuation of prior therapy if trials are not documented.
- Step: trial of two generics from listed antidepressants required prior to approval
- Failure to document trials of two generics may result in non-approval
- Approve for continuation of prior therapy
Atypical antipsychotic step requirement — documentation
Document trials of two listed generic atypical antipsychotics prior to approval of Fanapt products. Examples include asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone. Continuation of prior therapy is allowed.
- Step: trial of two listed generic atypical antipsychotics required prior to approval of Fanapt products
- Approve for continuation of prior therapy
Relistor step requirement — documentation
For Relistor, prior authorization requires documentation of prior trials of specified laxatives before approval is considered.
- Document prior trial(s) of lubiprostone, Constulose, Enulose, Generlac, or lactulose
- Failure to document trial of these laxatives may trigger denial
Rytary step requirement — documentation
For Rytary, prior authorization requires documentation of a trial of at least one generic carbidopa/levodopa formulation prior to approval.
- Document trial of one generic carbidopa/levodopa containing formulation
- Absence of such a trial may result in non-approval
Index content — no authorization or denial rules present
Many index pages included in this section contain only navigational entries (drug names, titration packs, scores/page references) and explicitly do not state authorization or denial triggers, step therapy details, or documentation requirements.
- No authorization or denial triggers are present in these index fragments
- No authorization or denial criteria present
- No authorization or denial rules present
- None stated in these index pages; no authorization or denial triggers present
- This section contains only index entries; it does not specify authorization or documentation requirements
- Index-only content; no authorization rules present
- This section is an index only; it does not contain PA rules
Definitions and Index Notes
Initial Therapy Requirements
Antidepressant initial therapy
Initial therapy requirements for certain antidepressant/branded products
Continuation approved for prior therapy.
Fanapt initial therapy
Initial therapy requirements for Fanapt products
Continuation approved for prior therapy.
Continuation of Prior Therapy
Continuation of prior therapy
Continuation of prior therapy is explicitly approved where noted.
Applies where continuation language is present in the excerpt.
Step Therapy Tables
| Step | Requirement | Applies to | Continuation Allowed |
|---|---|---|---|
| 1 | Trial of two generics from the following formulary products: bupropion; mirtazapine; citalopram (tablet or solution); desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline; venlafaxine hydrochloride. | New starts (initial therapy) | Approve for continuation of prior therapy. |
| Step | Requirement | Applies to | Continuation Allowed |
|---|---|---|---|
| 1 | Trial of two of the following oral generic formulary atypical antipsychotic agents: asenapine; aripiprazole; olanzapine; paliperidone; quetiapine; risperidone; ziprasidone. | New starts (Fanapt and titration packs) | Approve for continuation of prior therapy. |
| Step | Requirement | Applies to | Continuation Allowed |
|---|---|---|---|
| 1 | Trial of one of the following: Invega Sustenna or Invega Trinza. | New starts of Invega Hafyera | Approve for continuation of prior therapy. |
| Step | Requirement | Applies to | Continuation Allowed |
|---|---|---|---|
| 1 | Trial of generic zonisamide capsule. | New starts of Zonisade | Approve for continuation of prior therapy. |
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