South Carolina PDP Basic - Formulary step and trial requirements
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This document lists products on the South Carolina PDP Basic formulary and specific prior-authorization or step-therapy trial requirements that govern coverage and continuation of therapy for members and their providers.
No material clinical or coverage changes in this revision.
Coverage Criteria by Product
Diclofenac Sodium GEL 3% - Actinic keratosis
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of either topical fluorouracil or topical imiquimod
Formulary ID 26220, Version 10, effective 03/01/2026
Antidepressant-related products (e.g., Exxua, Auvelity, Emsam, Fetzima and packs)
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of two generics among: bupropion, mirtazapine, citalopram (tablet or solution), desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine hydrochloride
Approve for continuation of prior therapy; Formulary ID 26220, Version 10, effective 03/01/2026
Fanapt and related titration packs / Lybalvi / Secuado
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of two oral generic formulary atypical antipsychotic agents among: asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
Approve for continuation of prior therapy; Formulary ID 26220, Version 10, effective 03/01/2026
Invega Hafyera
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of one of: Invega Sustenna or Invega Trinza
Step applies to new starts only; approve for continuation of prior therapy; Formulary ID 26220, Version 10, effective 03/01/2026
Relistor
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of lubiprostone, Constulose, Enulose, Generlac, or lactulose
Formulary ID 26220
Zonisade
Covered when ALL of the following are met:
ALL of the following
- 1: Trial of generic zonisamide capsule
Step applies to new starts only; approve for continuation of prior therapy; Formulary ID 26220, Version 10, effective 03/01/2026
Initial (New Start) Therapy Requirements
Initial therapy requirements
Initial (new start) therapy requirements — step or prior trials required as specified per product.
ALL of the following
- Diclofenac_init: Trial of either topical fluorouracil or topical imiquimod required for Diclofenac Sodium GEL 3% new starts
Chunk 2
- Antidepressant_init: Trial of two generics from listed antidepressant group required for specified antidepressant/adjunct products; continuation allowed
Chunk 4
- Fanapt_init: Trial of two generic atypical antipsychotics required for Fanapt products new starts
Chunk 6
- Invega_init: Trial of Invega Sustenna or Invega Trinza required for Invega Hafyera new starts
Chunk 8
- Relistor_init: Trial of specified laxatives (lubiprostone, Constulose, Enulose, Generlac, or lactulose) required for Relistor
Chunk 10
- Zonisade_init: Trial of generic zonisamide capsule required for Zonisade new starts
Chunk 12
Continuation of Prior Therapy
Continuation approvals
Continuation of prior therapy is approved for listed products when members are already receiving therapy.
ANY of the following
- continuation: Approve for continuation of prior therapy when member is already on the medication
Applies across multiple listed products
Step Therapy Requirements (New Starts)
| Product | Step requirement (new starts) |
|---|---|
| Fanapt (including Fanapt titration packs) | Trial of two oral generic formulary atypical antipsychotic agents among: asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone |
| Product | Step requirement (new starts) |
|---|---|
| Antidepressant-related products (e.g., Exxua Titration Pack, Fetzima, Fetzima Titration Pack) | Trial of two generics among: bupropion, mirtazapine, citalopram (tablet or solution), desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine hydrochloride |
| Product | Step requirement (new starts) |
|---|---|
| Invega Hafyera | Trial of one of: Invega Sustenna or Invega Trinza (step applies to new starts only) |
| Zonisade | Trial of generic zonisamide capsule (step applies to new starts only) |
Provider Action & Documentation Requirements
Diclofenac Sodium GEL 3% prior auth
Prior authorization for Diclofenac Sodium GEL 3% requires documentation of a trial and lack of response or intolerance to either topical fluorouracil or topical imiquimod. Failure to document the required prior trial may result in denial of the prior authorization request.
- Affected product: Diclofenac Sodium GEL 3%
Antidepressant products prior auth
Prior authorization for select antidepressant products (including Exxua Titration Pack, Fetzima, and Fetzima Titration Pack) requires trial of two generic agents from the following group: bupropion, mirtazapine, citalopram (tablet or solution), desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine hydrochloride. Lack of documented trials for new starts may lead to non-approval. Continuation of prior therapy is approved when prior use is documented.
- Affected products: Exxua Titration Pack; Fetzima; Fetzima Titration Pack
Fanapt prior auth
For Fanapt products (including Fanapt Titration Pack C, Lybalvi, Secuado), prior authorization for new starts requires documentation of trial and failure or intolerance of two oral generic formulary atypical antipsychotics from the list: asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone. Continuation of prior therapy is approved when prior use is documented. Absence of these documented trials for new starts may result in denial.
- Required trial agents: asenapine; aripiprazole; olanzapine; paliperidone; quetiapine; risperidone; ziprasidone
- Affected products: Fanapt Titration Pack C; Lybalvi; Secuado
Invega Hafyera prior auth
Invega Hafyera prior authorization for new starts requires documentation of trial and inadequate response or intolerance to either Invega Sustenna or Invega Trinza. Step therapy applies to new starts only. Continuation of prior therapy is approved when prior use is documented; provide supply records or prior administration history to support continuation. Lack of a required prior trial may trigger denial for new starts.
- Step therapy: new starts must try Invega Sustenna or Invega Trinza first
- Documentation: supply records or prior administration history for continuation requests
Relistor prior auth
Prior authorization for Relistor requires documentation of a trial and inadequate response to one of the following laxatives: lubiprostone, Constulose, Enulose, Generlac, or lactulose. Absence of a documented trial of these agents may result in denial.
- Affected product: Relistor
- Required prior agents: lubiprostone; Constulose; Enulose; Generlac; lactulose
Zonisade prior auth
Zonisade prior authorization for new starts requires documentation of trial and failure or intolerance of a generic zonisamide capsule. Step therapy applies to new starts only. Continuation of prior therapy is approved when prior use is documented. Lack of the required trial for new starts may result in non-approval.
- Required prior agent: generic zonisamide capsule
- Step therapy: applies to new starts only
Provider documentation and denial risk
Document trials, failures, or intolerances of the required prior agents when submitting prior authorization requests. Failure to provide the requested documentation (e.g., trials of topical fluorouracil or imiquimod for Diclofenac Sodium GEL 3%, two generic antidepressants for certain antidepressant products, two generic atypical antipsychotics for Fanapt products, Invega Sustenna or Trinza for Invega Hafyera, specified laxatives for Relistor, or generic zonisamide for Zonisade) may lead to denial or non-approval of the request.
- Provide dates, duration, and reason for discontinuation (failure or intolerance) where applicable
- Include supply records or prior administration history for continuation requests
Background
This policy lists formulary-specific prior authorization and step-therapy requirements that apply to the South Carolina PDP Basic formulary (Formulary ID 26220, Version 10, effective 03/01/2026, last updated 02/02/2026). The requirements are intended to ensure use of formulary or generic alternatives where appropriate before coverage of select brand or specialty products, while allowing continuation of prior therapy for members already receiving the medication.
The document identifies specific initial (new start) therapy rules—for example, required trials of topical therapies for actinic keratosis, trials of listed generic antidepressants or atypical antipsychotics, and step requirements for certain long‑acting or specialty agents—and lists the products subject to those rules. It also specifies the documentation providers must submit to support prior authorization requests and notes the denial risk when required trials are not documented.
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