CurrentCignaPolicy N/A

Bile Acid Sequestrants Step Therapy Policy

Defines step therapy requirements for bile acid sequestrant products (cholestyramine, colestipol, colesevelam, and branded equivalents) administered under Cigna benefit plans; specifies Step 1 and Step 2 product lists and approval criteria for coverage for Step 2 products.

Policy Summary

PayerCigna

PolicyBile Acid Sequestrants Step Therapy Policy

Policy CodePolicy N/A

Change TypeAdministrative annual review

Effective Date

Next Review Date

Key ActionPrior authorization/coverage for a Step 2 bile acid sequestrant requires documentation that the patient has tried one Step 1 product; approvals are provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

Annual review entries note 'No criteria changes' for multiple review dates including 06/14/2023, 06/26/2024, and 06/18/2025.

2Step Levels (Step 1 and Step 2)

1 yearApproval Duration

1Required prior Step 1 trial before Step 2

Coverage Summary

Scope: Defines step therapy requirements for bile acid sequestrant products (cholestyramine, colestipol, colesevelam, and branded equivalents) administered under Cigna benefit plans, specifying Step 1 and Step 2 product lists and the requirement that a trial of a Step 1 product is required before a Step 2 product. Coverage stance: these products are covered with step-therapy criteria under Cigna plans; approvals are provided for 1 year. Subject: Bile Acid Sequestrants Step Therapy. Status: CURRENT.

Initial / Step Therapy Criteria

Step Therapy / Medical Necessity

Bile Acid Sequestrants Step Therapy Policy product(s) is(are) covered as medically necessary when the following step therapy criteria is(are) met. Any other exception is considered not medically necessary. All approvals are provided for 1 year in duration.

Step Therapy Requirement

Step 2 coverage requirement: Patient has tried one Step 1 Product
If the patient has tried one Step 1 Product, approve a Step 2 Product.

Applicable Products / Step-Level Codes

Step 1 Products (preferred first-line for step therapy)mixedCovered

	cholestyramine oral suspension (Questran, Questran Light, generic)
	colestipol oral suspension (Colestid) and colestipol micronized tablets
	colesevelam tablets and colesevelam oral suspension (Welchol and generics)
	Prevalite oral suspension

Step 2 Products (require prior trial of Step 1 product unless exception)mixedCovered

	Welchol tablets
	Welchol oral suspension
	Questran oral suspension
	Questran Light oral suspension
	Colestid oral suspension
	Colestid micronized tablets

Provider Actions

Prior Authorization

Step therapy requirement for Step 2 products

Prior authorization/coverage for a Step 2 bile acid sequestrant requires documentation that the patient has tried one Step 1 product; approvals are provided for 1 year.

Approval duration: 1 year
Required trial: 1 Step 1 product

Documentation Required

Documentation of prior trial

Provider must document trial of one Step 1 product to support coverage of a Step 2 product.

Examples of acceptable documentation: prior prescription records, chart notes showing trial and response, or pharmacy fill history

Background

Bile acid sequestrants are indicated as adjunctive therapy to diet (and exercise where specified) to reduce elevated LDL-C. Colesevelam additionally is approved for use in boys and postmenarchal girls aged 10 to 17 years with heterozygous familial hypercholesterolemia who cannot reach LDL-C targets with diet and lifestyle modification, and colesevelam is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Revision History

06/14/2023administrative review

Annual review — No criteria changes

06/26/2024administrative review

Annual review — No criteria changes

06/18/2025administrative reviewLatest

Annual review — No criteria changes

Policy Summary

PayerCigna

PolicyBile Acid Sequestrants Step Therapy Policy

Policy CodePolicy N/A

Change TypeAdministrative annual review

Effective Date

Next Review Date

Key ActionPrior authorization/coverage for a Step 2 bile acid sequestrant requires documentation that the patient has tried one Step 1 product; approvals are provided for 1 year.

SourceLink

On This Page

OpenPayer

Bile Acid Sequestrants Step Therapy Policy

Coverage Summary

Initial / Step Therapy Criteria

Unproven / Not Medically Necessary

Applicable Products / Step-Level Codes

Provider Actions

Clinical Evidence & References

Background

Revision History