CurrentCentenePolicy N/A

Step therapy exception request process — coverage criteria

Governs the process and required documentation for requesting an exception to pharmacy step therapy requirements for Centene members; applies to providers submitting exception requests (medical and pharmacy benefit).

Policy Summary

PayerCentene

PolicyStep therapy exception request process — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form with required supporting clinical documentation and medication history via fax to (800) 977-4170, CoverMyMeds, or mail to P.O. Box 31397 Tampa, FL 33631-3397.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number for submission

CoverMyMedsonline prior authorization portal referenced

P.O. Box 31397mailing address for submissions

Highlighted requiredform completion requirement

Coverage criteria for step therapy exceptions

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Exception Request Criteria

Covered when the exception request provides required documentation and meets clinical criteria:

Basic submission and documentation: Provider completes highlighted sections (provider and member information, drug information, diagnosis) and signs the form; includes prescriber NPI and TIN for medical benefit requests.

Source: form completion requirements and signature line

Medication history and prior use: If member is currently treated on the requested medication, indicate duration; document previous treatments with dates and reasons for discontinuation. Confirmation of prior use will be verified from member history on file and prior use of preferred drugs is part of the exception criteria.

Chunk 5

Continuation from prior plan: If request is for continuation of a previous approval from a prior health plan, provide documentation of that approval or valid claim history from the last 90 days.

Chunk 5

Clinical support: Provide appropriate clinical information to support medical necessity, including relevant lab reports or documentation; ensure the form is signed and dated by the provider.

Chunk 6

Covered when the exception request provides the required documentation and meets clinical criteria: the provider must complete all highlighted sections of the form including provider and member information, drug information, diagnosis, and sign the form; include the prescriber NPI and, for medical benefit requests, the requesting provider TIN and servicing provider/facility NPI and TIN. Medication history must document prior preferred drugs tried and reasons for discontinuation, and additional clinical information such as relevant lab reports (examples: culture and sensitivity, Hemoglobin A1C, serum creatinine, CD4, hematocrit, WBC) should be submitted to support medical necessity.

Provider submission requirements and actions

Prior Authorization

Step Therapy Exception Request Form Instructions

Complete the Step Therapy Form by filling in all highlighted sections. Incomplete forms will delay processing.

In section I, Provider Information: include prescriber's name, Provider NPI, and accurate fax and phone contact information. For medical benefit requests, include requesting provider's TIN and the NPI and TIN for the servicing facility or servicing provider.
In section II, Member Information: provide member's name, member ID, and date of birth; list relevant allergies, if any.
In section III, Drug Information: provide drug name, specific formulation (e.g., extended release, solution), strength, daily dose, valid diagnosis, and expected length of therapy. If member is already receiving the medication, complete the Medication History for this Diagnosis section with previous medications tried and failed.
In section IV, Additional Clinical Information: provide any additional relevant information and include lab reports when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC).
Provider signature and date are required.

Note

Submission options

Submit the completed form through one of the following options. When attaching electronically, include scanned supporting documentation (lab reports, prior approvals, clinical notes) with the prior authorization request.

Fax: (800) 977-4170
Electronic: attach to an electronic prior authorization request at https://www.covermymeds.com/main/prior-authorization-forms/
Mail: Centene Pharmacy Services - Coverage Determinations; P.O. Box 31397; Tampa, FL 33631-3397

Note

Exception request overview

This form requests an exception to step therapy requirements. Supporting documentation is required and prior use of preferred drugs will be verified as part of the exception criteria.

If requesting continuation from a prior health plan, provide documentation of approval or valid claim history from the last 90 days.
The Ambetter Formulary is available at www.ambetterhealth.com (select your state) — prior use of preferred drugs is part of the criteria.

Documentation Required

Required supporting documentation

Appropriate clinical information to support medical necessity must be submitted with the request. Examples of required supporting documentation include:

Relevant lab results (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC) when applicable.
Medication history for this diagnosis: indicate whether member is currently treated on the medication, duration, prior treatments (drug name, strength, dates of therapy), and reason for discontinuation.
Documentation of prior approvals or claim history if this is a continuation request from a prior plan.
Any additional clinical notes or diagnostic information that support medical necessity.

Denial Risk

Incomplete forms and denial risk

Incomplete forms or missing supporting documentation will delay processing and may result in denial of the request.

Previous Preferred Drug (name, strength, dose)	Dates of Therapy	Reason for Discontinuation / Outcome	Documentation Provided
(Enter preferred drug tried) e.g., Drug A 50 mg PO daily
(Enter start and stop dates) e.g., 01/2023 - 03/2023
(Select reason) e.g., lack of efficacy, adverse reaction, intolerance, non‑adherence
(Attach relevant records) e.g., clinical notes, lab results, claim history, prior approval documentation

Key definitions used on the form

Medication History — key elements

Currently treated on medicationYes/No question — if yes, indicate duration (go to item B); if no, skip to item C.

Continuation from prior planIndicate if request is for continuation of previous approval; if yes, provide documentation of prior approval or valid claim history from the last 90 days.

Previous treatmentsList prior therapies (drug name with strength and dosage), dates of therapy, and reason for discontinuation for up to four previous drugs.

Confirmation of useMembership claim history will be checked to confirm prior use; prior use of preferred drugs is part of exception criteria.

Formulary referenceAmbetter Formulary is available at www.ambetterhealth.com (search by state) to view specific preferred drug information.

Background on step therapy and exception rationale

Step therapy requires members to try preferred drugs before non-preferred alternatives; this form is used to request an exception to that requirement. Exceptions are considered when the submitted documentation demonstrates medical necessity — for example, prior treatment failure, intolerance, contraindication, or clinical factors supported by lab results. For continuation requests the provider must either document a prior approval from the former plan or supply a valid claim history from the last 90 days. Submit medication history showing prior therapies tried, dates, and reasons for discontinuation, and include applicable lab reports to justify the exception.

OpenPayer

Step therapy exception request process — coverage criteria

Coverage criteria for step therapy exceptions

Provider submission requirements and actions

Step therapy requirements and medication history

Continuation of therapy requirements

Key definitions used on the form

Background on step therapy and exception rationale