CurrentCignaPolicy N/A

Beta-Blocker and Sotalol Step Therapy Criteria

Defines Cigna's step therapy requirements for beta-blocker and sotalol products for applicable health benefit plans, specifying preferred generic first-step products and conditions for coverage of brand products.

Policy Summary

PayerCigna

PolicyBeta-Blocker and Sotalol Step Therapy Criteria

Policy CodePolicy N/A

Change TypeMaterial and operational updates

Effective DateN/A

Next Review DateJun 18, 2025

Key ActionObtain/use a Step 1A generic beta-blocker (or Step 1B generic sotalol) before approving Step 2A/2B brand products; approvals are for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Bisoprolol fumarate 2.5 mg tablets (Brand) was added to Step 2A with criteria to approve when the prescribed dose cannot be obtained with whole 5 mg or 10 mg tablets or if the patient has bronchospastic disease.

Bisoprolol/hydrochlorothiazide and nadolol/Bendroflumethiazide removed from Step 1A; Ziac and Dutoprol removed from Step 2A because they are no longer available.

Labetalol 400 mg tablet (brand) was added to Step 2A.

Step 1A vs Step 2ATiered rules

1 yearApproval duration

Two rulesProgram rules

NCApplicable state

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Coverage Criteria

Beta-Blocker and Sotalol Step Therapy Criteria

Products are covered as medically necessary when the corresponding step therapy requirements are met; any other exception is considered not medically necessary.

Program rules: Program comprises two rules: Beta-Blocker Step Therapy (Step A) and Sotalol Step Therapy (Step B). All approvals are provided for 1 year in duration.

Beta-Blocker Step A flow: Step 1A: patient must have tried one Step 1A generic product (examples: acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, carvedilol extended-release, labetalol, metoprolol tartrate, nadolol, pindolol, propranolol, timolol, metoprolol succinate extended-release, propranolol extended-release, or generic beta-blocker combination products) prior to approval of a Step 2A brand product.

Sotalol products do not count toward this requirement.

Bisoprolol fumarate 2.5 mg exceptions: Approve bisoprolol fumarate 2.5 mg tablets (brand) when either: the prescribed dose cannot be obtained using whole bisoprolol 5 mg or 10 mg tablets, OR the patient has bronchospastic disease.

Sotalol Step B flow: Step 1B: patient must have tried one Step 1B generic sotalol product prior to approval of a Step 2B product (brand Betapace or Betapace AF). If the requested Step 2B strength is not available generically, approve the Step 2B product.

Products subject to this step therapy policy are covered as medically necessary only when the applicable step therapy requirements are met. Any exception not meeting the step therapy criteria is considered not medically necessary.

Use of Step 2A or Step 2B products without first meeting the corresponding Step 1 requirements is not covered. Use of Step 2A or Step 2B products without meeting the corresponding Step 1 requirements is considered not medically necessary unless criteria-based exceptions apply.

Coding and Approval Duration

Coding guidancemixed

No codes listed

Approval duration — Step therapy exceptions

Standard approval duration1 year

When appliedApprovals for Step 2A or Step 2B products are provided for 1 year when step therapy criteria are met

Effect if step therapy unmetIf step requirements are not met at point of service, prior authorization is determined per criteria and coverage may be denied

Provider Actions & Prior Authorization

Step Therapy

Required step therapy flow

The step therapy program includes two sequential rules: Step A (Beta-Blocker Step Therapy) and Step B (Sotalol Step Therapy). Step A requires trial of a Step 1A generic beta-blocker before a Step 2A brand beta-blocker will be approved; Step B requires trial of generic sotalol (Step 1B) before approval of brand sotalol products (Step 2B). All approvals granted when criteria are met are valid for 1 year.

Step 1A: generic beta-blockers (e.g., acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, carvedilol ER, labetalol, metoprolol tartrate, nadolol, pindolol, propranolol, timolol, metoprolol succinate ER, propranolol ER) and generic beta-blocker combination products (e.g., atenolol/chlorthalidone, metoprolol/hydrochlorothiazide, propranolol/hydrochlorothiazide)
Step 2A: brand beta-blockers and brand beta-blocker combinations (e.g., Bystolic, Tenormin, Coreg, Coreg CR, Lopressor, Toprol XL, Corgard, Inderal LA, InnoPran XL, Inderal XL, Tenoretic, Lopressor HCT, metoprolol succinate/hydrochlorothiazide ER, Kapspargo Sprinkle, labetalol 400 mg tablet (brand), bisoprolol fumarate 2.5 mg tablet (brand))
Step 1B: generic sotalol
Step 2B: brand sotalol products (Betapace, Betapace AF)

Background

Beta-blockers are classified into pharmacologic subgroups including cardioselective, nonselective, combined alpha–beta blockers, and agents with intrinsic sympathomimetic activity (ISA). Cardioselective agents preferentially block beta‑1 receptors, though selectivity is dose dependent. Some beta‑blockers (for example carvedilol, metoprolol succinate extended‑release, and bisoprolol) have demonstrated benefit in heart failure with reduced ejection fraction.

Definitions

ISA — intrinsic sympathomimetic activity

Definition (ISA)Intrinsic sympathomimetic activity (ISA) — partial beta-receptor agonist activity resulting in less reduction of resting heart rate, cardiac output, and peripheral blood flow

Clinical effectAgents with ISA act as partial beta-agonists so resting heart rate and cardiac output are not reduced as much as with pure antagonists

Therapeutic implicationISA agents may have different safety profiles (e.g., less bradycardia) and are classified separately from cardioselective and nonselective beta-blockers

Beta-blockers indicated for heart failure

CarvedilolIndicated for heart failure; reduces mortality and HF hospitalization (also available as Coreg CR extended-release)

Metoprolol succinate (extended-release)