Step Therapy Drug List — Coverage Criteria
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.
No material clinical or coverage changes in this revision.
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.
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.
Category B requires two specific generics as Step 1
Requires trial of TWO generics as Step 1
Requires trial of TWO generics as Step 1
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
Provider Actions & Overrides
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.
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.
Provider must call override line to request exception
Provider must contact the override phone number (855-811-2218) to request a medical necessity exception when a Step 1 drug is not appropriate; the pharmacist will check claim history to verify prior Step 1 fills within the last 6–12 months.
- Call 855-811-2218 to request an override based on medical necessity.
- Pharmacist/system will review claims history for Step 1 fills in the previous 6–12 months when processing a Step 2 prescription.
Pharmacy may deny Step 2 at point of fill if Step 1 not filled within 6–12 months
If a prescription is a Step 2 medication and the member has not filled required Step 1 medication(s) within the prior 6–12 months, the pharmacy system will not automatically fill and may deny coverage until an approved override is obtained.
- Pharmacist/system checks claims history for prior Step 1 fills within the previous 6–12 months.
- Coverage may be denied at point of fill absent prior Step 1 fills or an approved medical necessity exception.
Mail-service pharmacy will not fill Step 2 without meeting step requirements
If a Step 2 prescription is submitted to the plan's home delivery (mail-service) pharmacy and step requirements are not met, the mail-service pharmacy will not fill the prescription and will notify the member by mail.
- Mail-service pharmacy will not dispense Step 2 medication without meeting step requirements or an approved override.
- The member will be notified by mail if the mail-service pharmacy does not fill the prescription.
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
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