Step Therapy Criteria for Selected Drugs
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Defines step therapy requirements for multiple pharmacy drugs, stating which generic alternatives must be tried before coverage of specified brand or alternative formulations is provided; applies to members under Carefirst Bluecross Blueshield Advantage Dualprime.
No material clinical or coverage changes in this revision.
Coverage Criteria and Drug-Specific Step Therapy
Drug-specific step therapy requirements
Coverage is provided when the listed trial requirements are met for each drug group.
agents listed: alendronate sodium, risedronate sodium
members must try two of three listed generics
This policy uses step therapy to manage coverage for the listed pharmacy products. For each product group, coverage is provided only after the member has tried the specified generic alternative(s) and the required trial duration is documented. In most groups the required trial is a 30-day supply of the listed generic alternative. For the PPI group the requirement is a trial of two distinct 30-day trials (two of: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules). These trial requirements must be met before prior authorization for the requested product will be approved.
Providers should document the specific generic agent(s) used and the duration of each trial in the member’s medical record to support authorization. Failure to document or attempt the required trial(s) — typically a minimum 30-day supply for each listed alternative (or two separate 30-day generic trials for the PPI group) — may result in denial of coverage.
Minimum Trial Duration and Coding Notes
Provider Requirements, Prior Authorization, and Documentation
Step therapy prior authorization
Prior authorization for the listed products requires documentation that the member has tried the specified generic alternative(s) for at least a 30-day supply before coverage will be approved.
General step therapy rule
Coverage for each listed product is provided only after a trial of the specified generic alternative(s) has been completed, typically a minimum 30-day supply.
Required documentation of prior trials
Document the member's prior trial(s) of the required generic alternative(s), including duration; for most groups this must show at least a 30-day supply, and for the PPI group documentation must show trials of two of the three listed generics.
- Show at least a 30-day supply trial for the applicable generic alternative(s).
- For PPI group, document trials of two of: omeprazole capsules, pantoprazole tablets, lansoprazole capsules.
Denial risk for missing step trials
Coverage may be denied if the required trial of the indicated generic alternative(s) is not documented or the minimum trial duration (generally 30 days, or two distinct 30-day trials for PPI) is not met.
Background
Step therapy is a utilization management strategy that requires trial and failure or intolerance of specified lower-cost or preferred alternatives before a requested medication is covered. This document lists the agent-specific alternatives and minimum trial durations (generally a 30-day supply) that must be completed prior to coverage of the associated branded or non-preferred products.
Definitions
Step Therapy Summary Table
| Step therapy group | Required trial before coverage |
|---|---|
| {"text":"ARIPIPRAZOLE ODT","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of generic aripiprazole immediate release tablet has been tried.","status":""} | |
| {"text":"BARACLUDE (entecavir)","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of generic entecavir tablets has been tried.","status":""} | |
| {"text":"BISPHOSPHONATES","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of alendronate, ibandronate, or risedronate has been tried.","status":""} | |
| {"text":"BRINZOLAMIDE","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of dorzolamide 2% ophthalmic solution has been tried.","status":""} | |
| {"text":"LAMOTRIGINE","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of generic lamotrigine immediate release tablets or generic lamotrigine chewable, dispersible tablet has been tried.","status":""} | |
| {"text":"LEVALBUTEROL","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of albuterol HFA or Ventolin HFA has been tried.","status":""} | |
| {"text":"OLANZAPINE ODT","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of generic olanzapine immediate release tablet has been tried.","status":""} | |
| {"text":"PPI","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of two of the following generic alternatives has been tried: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules (two distinct 30-day trials required).","status":""} | |
| {"text":"RISPERIDONE ODT","status":""}|{"text":"Coverage will be provided if at least a 30-day supply of generic risperidone immediate release tablet has been tried.","status":""} |
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