CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Drug coverage and step therapy rules (partial index)

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.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyDrug coverage and step therapy rules (partial index)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument trials of required generic agents (e.g., two generic antidepressants or two generic atypical antipsychotics) when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~13distinct products listed

multiplestep vs continuation entries

1actinic keratosis entry

20+index lines visible

Coverage Criteria (Index Excerpt)

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Antidepressant step requirement

Antidepressant products (Auvelity, Emsam, Exxua and related items)

Antidepressant step: 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.2 agents

Approve for continuation of prior therapy.

Atypical antipsychotic step requirement

Atypical antipsychotic products (Fanapt and titration packs)

Atypical antipsychotic step: Trial of two of the following oral generic formulary atypical antipsychotic agents: asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone.2 agents

Approve for continuation of prior therapy.

Invega Hafyera initial therapy

Invega Hafyera

Invega Hafyera step: Trial of one of the following: Invega Sustenna or Invega Trinza.1 agent

Step applies to new starts only. Approve for continuation of prior therapy.

Relistor initial therapy

Relistor

Relistor step: Trial of lubiprostone, Constulose, Enulose, Generlac, or lactulose required.1 agent

Rytary initial therapy

Rytary

Rytary step: Trial of one generic carbidopa/levodopa containing formulation required.1 agent

Zonisade initial therapy

Zonisade

Zonisade step: Trial of generic zonisamide capsule required.1 agent

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%)

Actinic keratosis topical step: Trial of either topical fluorouracil or topical imiquimod required.1 agent

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

Prior Authorization

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

Prior Authorization

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

Note

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

Note

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

Note

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

Step Therapy

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

Step 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

Documentation Required

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

Documentation Required

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

Note

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

Actinic keratosis topical therapies — Diclofenac Sodium GEL 3%

ProductDiclofenac Sodium GEL 3%

IndicationActinic keratosis (topical)

Required prior therapyTrial of either topical fluorouracil or topical imiquimod required

Source noteListed under 'Products Affected' with criteria specifying a trial of topical fluorouracil or imiquimod

Index of Drugs

SectionIndex Of Drugs

Example topicsAntidepressants; Atypical Antipsychotics; Diclofenac Sodium; Actinic Keratosis

PurposeNavigational index listing drug names and topic scores for locating policy sections

Index navigation markers and scores

Entry typeIndex entries with topic scores

Example scoreAntidepressants - Score 2; Atypical Antipsychotics - Score 3

UseServes as navigational markers to drug-specific policy sections

Index of Drugs

SectionIndex Of Drugs (continued)

Frequent entriesAuvelity, Diclofenac Sodium, Exxua, Emsam

NoteIndex lines repeat drug names and page references for navigation

SectionIndex Of Drugs

Repeated itemsExxua and Emsam appear repeatedly with page reference '2'

FunctionTable of contents style listing to locate full policy pages

Index of Drugs

Index entriesExxua; Exxua Titration Pack; Emsam

Page referencesMultiple lines show page '2' for these entries

PurposeIndex repeats to support locating detailed drug entries elsewhere in the document

Index of Drugs

Highlighted drugExxua

Associated itemsExxua Titration Pack; Fetzima Titration Pack also referenced

Navigation roleIndex lines reference titration packs and other related entries to guide readers to policy pages

Index — drug names and titration packs

Index labelIndex

ContentDrug names and titration packs listed as navigation to policy pages

ExamplesFanapt; Fanapt Titration Pack A/B; Fetzima Titration Pack

Exxua

Drug nameExxua

Index presenceListed repeatedly in the index fragment

Clinical definitionNo clinical definition provided in the index fragment

Titration Pack

TermTitration Pack

DefinitionA packaged set of incremental doses of a medication used to initiate and adjust therapy

Use in documentListed in the index to identify titration pack policy pages (e.g., Fanapt Titration Pack A/B)

Index Of Drugs

SectionIndex Of Drugs

ContentLists drug names and associated titration packs as part of the policy table of contents

ExamplesFanapt; Fanapt Titration Pack A; Fanapt Titration Pack B

Fanapt / Fanapt Titration Pack

DrugFanapt

Associated itemsFanapt Titration Pack A and Fanapt Titration Pack B

Index roleEntries serve as navigation to the Fanapt policy and titration pack pages

Index of Drugs — Fanapt titration packs A and B

Index entryFanapt Titration Pack A; Fanapt Titration Pack B

PurposeIndex listing referencing titration pack variants to help locate detailed policy sections

Example contextAppears in repeated index lines showing page '3' for Fanapt and its packs

OpenPayer

Drug coverage and step therapy rules (partial index)

Coverage Criteria (Index Excerpt)

Provider Actions and Documentation Requirements

Definitions and Index Notes

Initial Therapy Requirements

Continuation of Prior Therapy

Step Therapy Tables