CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Formulary step therapy and prior authorization requirements — Behavioral health agents

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.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyFormulary step therapy and prior authorization requirements — Behavioral health agents

Policy CodePolicy N/A

Change TypeNo material changes reported

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionDocument trials of the required generic alternatives (e.g., two generics for antidepressants or two generic atypical antipsychotics) when submitting prior authorization for new starts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~12distinct product entries

Version 18formulary version

11/01/2025effective date shown

10/01/2025last updated

20+

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

index chunks repeated

Coverage Criteria and Step Therapy

Antidepressant step therapy (Exxua, Fetzima, etc.)

Covered when ALL of the following are met for new starts:

Antidepressant step: Trial of two generics from the following list: bupropion, mirtazapine, citalopram (tablet or solution), desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline (tablet or solution), venlafaxine hydrochloride.two agents

Approve for continuation of prior therapy.

Atypical antipsychotic step therapy (Fanapt)

Covered when ALL of the following are met for new starts:

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

Approve for continuation of prior therapy.

Invega Hafyera prior therapy requirement

Covered when ALL of the following are met for new starts:

Invega Hafyera prior trial: Trial of one of the following: Invega Sustenna or Invega Trinza.one agent

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:

Memantine/donepezil ER prior trial: Trial of generic memantine extended-release.one agent

Relistor prior therapy requirement

Covered when ALL of the following are met:

Relistor prior trial: Trial of lubiprostone, Constulose, Enulose, Generlac, or lactulose.one agent

Rytary prior therapy requirement

Covered when ALL of the following are met for new starts:

Rytary prior trial: Trial of one generic carbidopa/levodopa containing formulation.one agent

Zonisade prior therapy requirement

Covered when ALL of the following are met for new starts:

Zonisade prior trial: Trial of generic zonisamide capsule.one agent

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

Step Therapy

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

Note

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

Index and Coding References

Index entries (not codes)mixed

No codes listed

Index entries (drug names)mixed

No codes listed

Pharmacotherapy Step Requirements

Pharmacotherapy (antidepressants, antipsychotics, other CNS agents)

Pharmacotherapy (antidepressants, antipsychotics, other CNS agents): Step therapy requires trials of specified generic agents prior to coverage of branded behavioral health medications; continuation of prior therapy is permitted.varies by product

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

inv-82: Trial — Antidepressant step therapy

RequirementDocumented trial of two generic antidepressant agents from the following list: bupropion; mirtazapine; citalopram (tablet or solution); desvenlafaxine succinate ER; duloxetine; escitalopram; fluoxetine; fluvoxamine; paroxetine; sertraline (tablet or solution); venlafaxine hydrochloride.

ScopeApplies to new starts of listed branded products (e.g., Exxua, Fetzima, Exxua Titration Pack).

Continuation of prior therapyContinuation of existing therapy is approved and not subject to the new-start step requirement.

Formulary/versionFormulary ID: 25383; Version: 18; Effective Date: 11/01/2025.

Documentation neededMedical record must document trials of the two specified generic agents to support prior authorization for initiation.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyFormulary step therapy and prior authorization requirements — Behavioral health agents

Policy CodePolicy N/A

Change TypeNo material changes reported

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionDocument trials of the required generic alternatives (e.g., two generics for antidepressants or two generic atypical antipsychotics) when submitting prior authorization for new starts.

SourceLink

On This Page

None — this excerpt is an index and does not specify documentation, prior authorization, or denial triggers

Documentation Required

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

Note

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

inv-83: New starts — Invega Hafyera

RequirementTrial of one of the following prior to approval for new starts: Invega Sustenna or Invega Trinza.

ScopeStep applies to new starts of Invega Hafyera; continuation of prior therapy is approved.

Formulary/versionFormulary ID: 25383; Version: 18; Effective Date: 11/01/2025.

Documentation neededMedical record must document trial of Invega Sustenna or Invega Trinza for prior authorization of new starts.

Approval noteApprove for continuation of prior therapy without requiring the step trial.