Step Therapy Criteria (Pharmacy)
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This document lists step therapy requirements for specific drugs, stating which lower-cost or generic alternatives must be tried (typically for at least a 30-day supply) before coverage is provided. It applies to drug benefit coverage determinations under CareFirst BlueCross BlueShield Advantage DualPrime.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial step therapy requirements
Coverage provided when ALL of the following are met for each listed drug group
ARIPIPRAZOLE ODT group
BARACLUDE group
BRINZOLAMIDE group
LAMOTRIGINE ER / SUBVENITE group
LEVALBUTEROL TARTRATE HFA group
OLANZAPINE ODT group
PPI group requires two different generics
RISPERIDONE ODT group
Initial Therapy (Step) Requirements
Required initial trials
Initial therapy (step) requirements for listed drugs
Step Therapy Details
| Step Therapy Group | Required prior trial (agents and duration) | Coverage |
|---|---|---|
| ARIPIPRAZOLE ODT | ||
| A 30-day supply of generic aripiprazole immediate‑release tablet has been tried. | ||
| Coverage provided when requirement met. | ||
| BARACLUDE | ||
| A 30-day supply of generic entecavir tablets has been tried. | ||
| Coverage provided when requirement met. | ||
| BRINZOLAMIDE | ||
| A 30-day supply of dorzolamide 2% ophthalmic solution has been tried. | ||
| Coverage provided when requirement met. | ||
| LAMOTRIGINE ER / SUBVENITE | ||
| A 30-day supply of generic lamotrigine immediate‑release tablets or generic lamotrigine chewable/dispersible tablet has been tried. | ||
| Coverage provided when requirement met. | ||
| LEVALBUTEROL TARTRATE HFA | ||
| A 30-day supply of albuterol HFA or Ventolin HFA has been tried. | ||
| Coverage provided when requirement met. | ||
| OLANZAPINE ODT | ||
| A 30-day supply of generic olanzapine immediate‑release tablet has been tried. | ||
| Coverage provided when requirement met. | ||
| PPI (ESOMEPRAZOLE MAGNESIUM) | ||
| A 30-day supply of two of the following generics has been tried: omeprazole capsules; pantoprazole tablets; or lansoprazole capsules. | ||
| Coverage provided when requirement met. | ||
| RISPERIDONE ODT | ||
| A 30-day supply of generic risperidone immediate‑release tablet has been tried. | ||
| Coverage provided when requirement met. |
Provider Actions & Requirements
Prior authorization requires documented trial
Prior authorization requests must include evidence that the member has tried the specified generic or alternative product for at least a 30-day supply (for the PPI group, evidence of trials of two specified generics is required) before coverage will be approved.
- At least a 30-day supply trial of the listed generic/alternative is required for each step therapy group.
- PPI group requires trials of two of the listed generics (omeprazole, pantoprazole, or lansoprazole) for at least 30 days each as applicable.
Step therapy requirement
Providers must confirm the member completed the required prior trial(s) — typically a 30-day supply of the listed generic or alternative agent(s) — before the named drug will be covered.
- For most groups, a 30-day supply of the specified generic alternative must have been tried (see each group for the exact agent).
- PPI group: two different 30-day generic trials (omeprazole capsules, pantoprazole tablets, or lansoprazole capsules) are required.
Required documentation for step trials
Documentation submitted with the authorization or claim should show a trial of the specified generic or alternative medication for at least a 30-day supply where a step is required.
- Include dates, medication name, dosage, and days supplied to demonstrate a 30-day trial.
- For PPI group requests, document trials of two different listed generics for 30 days each.
Denial risk when step trial missing
Coverage may be denied if the member has not completed the required trial(s) of the specified generic or alternative medication (typically a 30-day supply) prior to requesting the listed branded or specialty product.
- Denial risk applies when no documentation of the required 30-day trial is provided.
- PPI group denials may occur if two required generic trials are not documented.
Coding & Trial Duration
Definitions
Background
Step therapy (fail-first) requires that a member try specified lower-cost or established alternative medications before coverage of certain branded or specialty formulations is provided. For the groups listed in this policy, coverage is contingent on completion of the specified prior trial(s) as described below.
In this policy the typical required trial duration is a 30-day supply. For most listed drug groups the member must have tried a single generic or alternative for at least a 30-day supply prior to coverage. The PPI group is an exception: coverage requires trials of two different generic alternatives for at least a 30-day supply each (choices include omeprazole capsules, pantoprazole tablets, or lansoprazole capsules).
Providers requesting coverage or prior authorization must document that the member completed the required step therapy trial(s) (typically a 30-day supply of the specified generic/alternative). Coverage may be denied if the required trial(s) are not documented.
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