CurrentCignaPolicy N/A

Beta Blocker Step Therapy Policy

Defines step therapy requirements for beta-blocker products administered under Cigna health benefit plans, specifying preferred generic Step 1 products and criteria to cover Step 2 (brand or non-preferred) products. Affects prescribers and pharmacy benefit adjudication for Cigna-covered members.

Policy Summary

PayerCigna

PolicyBeta Blocker Step Therapy Policy

Policy CodePolicy N/A

Change TypeAdded/Updated step therapy products

Effective DateN/A

Next Review DateN/A

Key ActionTry a Step 1 product before requesting Step 2 coverage; approvals are provided for 1 year with listed exceptions allowing bypass of the step requirement.

SourceLink

POLICY UPDATE CHANGES

Labetalol 400 mg tablet (brand) was added to Step 2 of the Beta Blocker Step Therapy.

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

Lopressor oral solution was added to Step 2A and an approval exception was added for patients who cannot swallow tablets.

Removed several combination products from Step 1A/2A because they are no longer available.

2step therapy rules

Step 1A & Step 2Aproduct lists

1 yearapproval duration

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Coverage Criteria for Beta-Blocker Step Therapy

Step therapy coverage criteria

Covered when ALL of the following are met according to the relevant step rule

Beta-Blocker Step A general rule: If the patient has tried one Step 1A Product, approve a Step 2A Product.1 prior Step 1A product tried

Sotalol products do not count toward this requirement.

Bisoprolol fumarate 2.5 mg exceptions: Approve bisoprolol fumarate 2.5 mg tablets if either (a) the prescribed dose cannot be obtained with whole bisoprolol 5 mg or 10 mg tablets OR (b) the patient has bronchospastic disease.

Specific to brand bisoprolol fumarate 2.5 mg tablet (Step 2A).

Lopressor oral solution exception: Approve Lopressor oral solution if the patient cannot swallow or has difficulty swallowing tablets.

Oral solution is listed in Step 2A with swallow-difficulty exception.

Sotalol Step B general rule: If the patient has tried one Step 1B Product, approve a Step 2B Product.

If the strength of the requested Step 2B product is not available generically, approve the Step 2B product.

Any product that does not meet the specified step therapy criteria or one of the listed approval exceptions is considered not medically necessary under this policy.

Any exception that is not explicitly listed in the step therapy criteria and exceptions is considered not medically necessary for coverage purposes.

Provider Requirements, Prior Authorization, and Denial Risk

Denial Risk

Coverage denial risk for unmet step therapy

If the Step Therapy rule is not met for the requested Step 2A or Step 2B product at the point of service, coverage will be determined by the Step Therapy criteria below; approvals are provided for 1 year.

All approvals are valid for 1 year from the approval date.

Step Therapy

Step therapy prior authorization requirements

Step therapy prior authorization requires that a member try a Step 1 product before coverage of a Step 2 product. Providers must document prior use of the required Step 1 product or meet a listed exception.

If the required Step 1 product was not tried, coverage of the Step 2 product may be denied at point of service.
Sotalol products do not count toward the Beta-Blocker Step Therapy Step 1A requirement.

Coding Guidance

Guidance - codingmixed

No codes listed

Key Definitions

ISA — Intrinsic sympathomimetic activity definition and implications

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

Clinical implication 1Agents with ISA may produce smaller decreases in resting heart rate and cardiac output compared with pure beta antagonists, potentially altering tolerability in some patients.

Clinical implication 2ISA-containing beta-blockers (e.g., acebutolol, penbutolol, pindolol) may be preferred when avoidance of marked bradycardia or reduction in peripheral blood flow is desired.

Classification contextISA is one of four pharmacologic subgroups used to classify beta-blockers alongside cardioselective, nonselective, and combined alpha-beta blockers.

Dose/selectivity noteCardioselectivity and pharmacologic effects can be dose-dependent; ISA effects likewise influence hemodynamic response compared with non-ISA agents.

Background and Rationale

Beta-blockers are categorized by receptor activity into cardioselective, nonselective, combined alpha–beta, and agents with intrinsic sympathomimetic activity (ISA). Cardioselectivity can be dose-dependent and may diminish at higher doses. Several beta-blockers also have distinct clinical indications beyond hypertension, including angina, arrhythmia management, post–myocardial infarction mortality reduction, and heart failure therapies. The policy implements two parallel step therapy rules: the Beta-Blocker Step Therapy (Step A) and the Sotalol Step Therapy (Step B), which require trial of a Step 1 product before approval of a corresponding Step 2 product, with specified exceptions.