Formulary step therapy and prior authorization requirements — Behavioral health agents
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Lists products subject to step therapy or prior trials and the specific trial requirements for approval; affects prescribers and pharmacy benefit administrators for Blue Cross Blue Shield - South Carolina members. Covers antidepressants, atypical antipsychotics, select CNS agents, and other listed products.
No material clinical or coverage changes in this revision.
Coverage Criteria and Step Therapy
Antidepressant step therapy (Exxua, Fetzima, etc.)
Covered when ALL of the following are met for new starts:
Approve for continuation of prior therapy.
Atypical antipsychotic step therapy (Fanapt)
Covered when ALL of the following are met for new starts:
Approve for continuation of prior therapy.
Invega Hafyera prior therapy requirement
Covered when ALL of the following are met for new starts:
Step applies to new starts only. Approve for continuation of prior therapy.
Memantine/donepezil ER prior therapy requirement
Covered when ALL of the following are met:
Relistor prior therapy requirement
Covered when ALL of the following are met:
Rytary prior therapy requirement
Covered when ALL of the following are met for new starts:
Zonisade prior therapy requirement
Covered when ALL of the following are met for new starts:
Step applies to new starts only. Approve for continuation of prior therapy.
For the products listed in this section, continuation of prior therapy is approved and therefore those continuing members are not subject to the new-start step therapy requirements. This exception to step requirements is explicitly noted alongside each product-specific criterion (for example, antidepressant and atypical antipsychotic entries) and applies when the member is already established on the branded therapy.
Providers submitting prior authorization requests should indicate when the request is for continuation of an existing therapy; documentation that the member is currently receiving the medication supports application of this continuation exception and avoids new-start step requirements.
This excerpt is an index of drug names, categories, and score/page references and does not itself state coverage, exclusion, or medical necessity criteria. For coverage determinations and specific step or prior-auth requirements, refer to the individual drug policy sections referenced by the index entries.
Documentation, Trials, and Prior Authorization - Provider Actions
Atypical antipsychotic step therapy requirement
Prior authorization requires trial of two oral generic formulary atypical antipsychotic agents (asenapine, aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone) prior to approval of certain branded atypical antipsychotic products. Approve for continuation of prior therapy.
- Step therapy applies to new starts; existing therapy may be continued
- Affected products (examples): Fanapt, Lybalvi, Secuado
Prior authorization not specified in this section (index only)
This section is an index/listing and does not itself specify prior authorization rules, affected billing codes, or detailed authorization/denial criteria. Refer to the drug-specific policy pages referenced in the index for full prior authorization and coverage requirements.
- Index directs to drug-specific prior authorization sections — see individual drug policy entries for requirements
- No prior authorization specified in this index excerpt; no affected codes listed
- None — this excerpt is an index and does not specify documentation, prior authorization, or denial triggers
Documentation of prior therapy and required trials
Documentation must show trials of required alternative therapies where specified. Examples: trial of Invega Sustenna or Invega Trinza is required for new starts of Invega Hafyera (approval for continuation of prior therapy is allowed); trial of one generic carbidopa/levodopa formulation is required before Rytary; trial of generic memantine ER is required for memantine/donepezil ER where noted. Absence of documented required prior trials may result in denial.
- Invega Hafyera (new starts): trial of Invega Sustenna or Invega Trinza required; continuation of prior Hafyera therapy may be approved
- Rytary: trial of one generic carbidopa/levodopa formulation required prior to approval
- Memantine/donepezil ER (Namzaric): trial of generic memantine ER required
Index content only — no authorization or documentation instructions
Many index chunks contain only repeated headings, drug name lists, or page/score references and do not include authorization, documentation, or denial instructions. No step therapy, documentation, or denial-risk rules are provided in those index fragments.
- These chunks contain only index headers/repeated listings — consult referenced policy pages for actions
- No documentation requirements provided in these index excerpts
- No authorization or denial criteria present in these index chunks
Index and Coding References
| No codes listed |
| No codes listed |
Pharmacotherapy Step Requirements
Pharmacotherapy (antidepressants, antipsychotics, other CNS agents)
See individual product entries.
Background and Scope Summary
This document segment summarizes formulary step therapy and prior trial requirements for selected central nervous system and behavioral health agents. For new therapy starts, the policy generally requires documented trials of specified generic alternatives before coverage of certain branded products—for example, a trial of two generic antidepressants from the listed agents is required for initiation of branded antidepressant entries, and a trial of two generic oral atypical antipsychotics is required for Fanapt. Single-step alternatives are specified for some products (for example, a trial of Invega Sustenna or Invega Trinza is required for new starts of Invega Hafyera).
The policy consistently notes that these step requirements apply to new starts, while patients already receiving the branded therapy may be continued—approval for continuation of prior therapy is expressly allowed in the applicable product entries.
Definitions
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