CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Step Therapy Drug List — Coverage Criteria

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Defines Step 1 and Step 2 medication ordering and coverage rules for affected Blue Cross Blue Shield - South Carolina plans and explains pharmacy/provider processes for overrides and exceptions.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyStep Therapy Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionProviders must call 855-811-2218 to request a medical necessity override when prescribing a Step 2 medication instead of required Step 1 drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-10-01policy effective date

6-12 molookback period

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CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Step Therapy Drug List — Coverage Criteria

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - South Carolina policy alerts

Know when Blue Cross Blue Shield - South Carolina releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines Step 1 and Step 2 medication ordering and coverage rules for affected Blue Cross Blue Shield - South Carolina plans and explains pharmacy/provider processes for overrides and exceptions.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyStep Therapy Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionProviders must call 855-811-2218 to request a medical necessity override when prescribing a Step 2 medication instead of required Step 1 drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-10-01policy effective date

6-12 molookback period

Coverage Criteria

Initial Step Therapy Requirement

Coverage for Step 2 drugs is conditioned on meeting the listed Step 1 requirements or obtaining an approved medical necessity override.

Standard step requirement: Member must have tried one or more specified Step 1 drugs for the condition before Step 2 coverageprior fill(s) within 6-12 months where specified

In some categories TWO generics are required as Step 1 (document lists where applicable)

Initial Therapy (Step 1 Required)

Initial therapy (Step 1 required)

For each listed condition the document specifies required Step 1 drug(s) that must be tried before Step 2 drugs are covered.

Acne (A): Step 1: try generic topical tretinoin before coverage of Step 2 agents (Fabior, Tazorac) or obtain an override

Acne (B): Step 1: try generic adapalene gel AND generic topical tretinoin before coverage of Step 2 agents (Adapalene solution, Adapalene‑Benzoyl Peroxide Gel) or obtain an override

Category B requires two specific generics as Step 1

Actinic keratosis: Step 1: try imiquimod 5% before coverage of imiquimod 3.75% or obtain an override

ADHD: Step 1: try one or more of amphetamine‑dextroamphetamine IR/ER, dextroamphetamine IR/SR, methylphenidate IR/ER, dexmethylphenidate IR/ER, or lisdexamfetamine before coverage of Step 2 agents (Azstarys, Jornay PM, Quillivant XR, Qelbree, Methylphenidate Patch, Xelstrym) or obtain an override

Asthma: Step 1: try one or more of Qvar or Arnuity before coverage of Fluticasone HFA or obtain an override

Behavioral health: Step 1: try TWO of the listed generics (aripiprazole, clozapine/ODT, olanzapine, paliperidone, quetiapine, quetiapine extended release, risperidone, ziprasidone) before coverage of long‑acting or other Step 2 agents (Abilify Maintena, Aristada, Asenapine, Caplyta, Fanapt, Invega, Latuda, Lurasidone, Rexulti, Risperdal Consta, Uzedy, Vraylar) or obtain an override

Requires trial of TWO generics as Step 1

Depression: Step 1: try one or more of desvenlafaxine extended‑release (generic for Pristiq), venlafaxine, or venlafaxine extended release before coverage of Step 2 agents (Fetzima, desvenlafaxine ER 24hr) or obtain an override

Fungal infections: Step 1: try one or more of clotrimazole 1% cream, ketoconazole 2% cream, or miconazole 1%–2% cream before coverage of oxiconazole 1% cream and lotion or obtain an override

Gout: Step 1: try allopurinol before coverage of febuxostat or obtain an override

High Cholesterol: Step 1: try one or more of atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin before coverage of Step 2 agents (Livalo, pitavastatin) or obtain an override

Hypertension: Step 1: try one or more generic ACE‑Inhibitors or generic ARBs before coverage of Edarbi or Edarbyclor or obtain an override

Phosphate binders: Step 1: try TWO of these generics: calcium acetate, sevelamer carbonate, lanthanum carbonate before coverage of Step 2 agents (Auryxia, Ferric Citrate, Velphoro) or obtain an override

Requires trial of TWO generics as Step 1

Seizures: Step 1: try one or more of lamotrigine IR, levetiracetam IR, levetiracetam ER, oxcarbazepine IR, or topiramate IR before coverage of Step 2 agents (Briviact, Topiramate ER, Xcopri) or obtain an override

Sleep Disorder: Step 1: try one or more of doxepin, eszopiclone, temazepam, zaleplon, or zolpidem/ER before coverage of Belsomra or obtain an override

Thyroid Disorder: Step 1: try levothyroxine before coverage of Synthroid or obtain an override

Step Therapy Details

Step	Requirement
Step 1	Try one or more specified Step 1 drug(s) first for the listed condition, or the provider must request a medical necessity override (examples: acne — generic topical tretinoin; acne (B) — generic adapalene gel AND generic topical tretinoin; behavioral health — TWO generics required where listed).

Step	Coverage condition
Step 2	Coverage for Step 2 drugs is provided only if the member has met the Step 1 requirement (trial of the listed Step 1 drug(s) within the prior 6–12 months where specified) or an approved medical necessity override is obtained; pharmacies may deny fill or require override verification (mail-service will not fill if requirements not met).

Coding / Operational Parameters

Step lookback (Step therapy requirement)

Lookback window6-12 months prior pharmacy fills are used to satisfy required Step 1 therapy

Pharmacy verificationPharmacist/computer system checks member claims history for Step 1 fills within the prior 6-12 months

Effect of no prior Step 1 fillIf no Step 1 fill is found in the 6-12 month window, the pharmacy may not automatically fill the Step 2 medication

Mail-service ruleHome-delivery (mail) pharmacy will not fill a Step 2 prescription that does not meet step requirements and will notify the member by mail

Provider Actions & Overrides

Prior Authorization

Medical necessity override required for Step 2

Providers must call 855-811-2218 to request a medical necessity override when prescribing a Step 2 medication instead of required Step 1 medication(s).

Call the override line to request a medical necessity exception when a Step 1 drug is not appropriate.

Step Therapy

Member must trial required Step 1 drugs before Step 2 coverage

Members must try the required Step 1 drug(s) listed for each condition before coverage is provided for associated Step 2 drugs; providers may request an override if a Step 1 drug is not appropriate.

Per-condition Step 1 requirements are specified in the policy (examples: acne, ADHD, asthma, behavioral health, depression, seizures, etc.).
Some categories require trials of TWO generics as the Step 1 requirement where noted.

Background

Step therapy is a tiered medication management program that requires members to try lower‑cost, preferred Step 1 options before coverage is provided for higher‑cost or non‑preferred Step 2 medications. The program is based on FDA and manufacturer dosing guidance, medical literature, safety, accepted medical practice and benefit design to promote clinically appropriate, cost‑effective therapy choices for members. [[1]]

Definitions

Step therapy program overview

DefinitionStep therapy is a program that requires members to try cost-effective 'Step 1' medications before trying more expensive 'Step 2' medications

PurposeDesigned to help lower medication costs while relying on FDA guidance, dosing, safety, medical literature, and accepted practice

Member options when Step 1 requiredMember or pharmacist can switch to a Step 1 drug, pay full price for Step 2, or request a medical necessity exception

Coverage dependencyCoverage for Step 2 drugs is conditional on prior trial of Step 1 drugs or an approved medical necessity override