CurrentCignaPolicy 1801

Step Therapy - Standard and Performance Prescription Drug Lists (Employer Group Plans)

Defines step therapy requirements (Step 1/2/3) for multiple drug classes on Cigna Standard and Performance Prescription Drug Lists for employer group plans, including when exceptions apply and plan-specific step counts (Complete, Essential, Limited). Governs prior authorization/medical necessity determinations for listed brand drugs.

Policy Summary

PayerCigna

PolicyStep Therapy - Standard and Performance Prescription Drug Lists (Employer Group Plans)

Policy CodePolicy 1801

Change TypeMultiple revisions (removals, additions, clarifications)

Effective DateMar 1, 2026

Next Review Date

Key ActionStep 3 medications generally require step therapy and prior authorization; document prior trials, inadequate response, intolerance, or contraindications to required Step 1/Step 2 agents in the prior authorization request.

POLICY UPDATE CHANGES

Removed Aciphex, Altace, Avapro, Cozaar, Fanapt, and Zestril from the policy.

Clarified Anti-Parkinsonism Drugs step therapy requirements apply to MAO-B inhibitors and added new step therapy requirements for Carbidopa and Levodopa Products Crexont and Rytary.

Removed Benicar, Benicar HCT, Caplyta, Celebrex, Diovan, Diovan HCT, Rexulti, Vraylar, and Vytorin from the policy; added Ophthalmic Corticosteroids section with Inveltys and Lotemax products as Step 3 and added Zoryve to Non-Steroidal Topical as Step 3.

Removed Actonel, Adderall, Avalide, Evekeo, Fetzima, Hyzaar, Invega, Micardis, Prevacid and Protonix from Step 3; added Auvelity as an Antidepressant Step 3 medication.

Updated the Auvelity requirement and removed Prozac Weekly and Sarafem.

MultipleDrug classes covered (count approximate)

VariesPlan-specific Step counts (Complete/Essential/Limited)

Coverage Summary & Scope

This Coverage Policy (Cigna policy number 1801) governs step therapy for employer group Prescription Drug Lists (Standard and Performance). It defines three step categories (Step 1/Step 2/Step 3) and applies to multiple drug classes across the Standard and Performance Prescription Drug Lists for employer group plans. The policy establishes that Step 1 and Step 2 medications are generally automatically covered without prior authorization, while Step 3 medications generally require step therapy and prior authorization when the prescriber intends to initiate therapy with a Step 3 agent.

Prior authorization for Step 3 agents requires documentation that the patient had a documented failure, inadequate response, contraindication per FDA label, or intolerance to the number of required Step 1 and/or Step 2 agents specified by the plan (Complete, Essential, Limited). Exceptions to step therapy are specified for certain classes and clinical scenarios (for example, diabetes metformin exceptions, ophthalmic corticosteroid allergy to benzalkonium chloride, exceptions for patients currently stabilized on specific products, and age-based exceptions for non-steroidal topical agents). The policy notes that receipt of sample product does not satisfy prior trial requirements.

Policy metadata

policy_number1801

coverage_stancecovered_with_criteria

subjectStep Therapy - Standard and Performance Prescription Drug Lists (Employer Group Plans)

payerCigna

effective_date2026-03-01

last_review2026-03-01

General Step Therapy Coverage Criteria

Cigna approves coverage for brand name drugs as medically necessary when prerequisites are met; see plan-specific required Step 1/Step 2 trials and exceptions.

ALL of the following

Step therapy requirement: Patient must have documented failure, inadequate response, contraindication per FDA label, or intolerance to the required number of Step 1 and/or Step 2 agents for the applicable plan (Complete, Essential, Limited) as specified per drug class.
Providers must document prior trials, inadequate response, intolerance, or contraindications; receipt of samples does not satisfy criteria.
Samples: Receipt of sample product does not satisfy criteria requirements.
Dosage and site of care: Dosage, frequency, duration, and site of care must be reasonable, clinically appropriate, and supported by evidence-based literature.

Class-specific Exceptions and Clinical Overrides

Class-specific exceptions (examples captured)

Diabetes Care - metformin requirement exceptions

Dual therapy initiation: If initiating dual therapy with metformin AND Farxiga or Jardiance, approve Farxiga or Jardiance.
Contraindication to metformin: If patient has a contraindication to metformin per prescriber, approve Farxiga or Jardiance.
Examples of contraindications include acute or chronic metabolic acidosis, including diabetic ketoacidosis.
HFrEF: If patient has heart failure with reduced ejection fraction (HFrEF), approve Farxiga or Jardiance.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior authorization required for Step 3 medications

Step 3 medications generally require step therapy and prior authorization when physician wants to start with a Step 3; approval requires documentation of failure/intolerance/contraindication to required Step 1/2 agents as specified by plan.

Initiation of a Step 3 medication requires documentation of failures, inadequate response, intolerance, or contraindication to the number of required Step 1 and/or Step 2 agents for the member's plan (Complete, Essential, Limited).

Documentation Required

Document failures/intolerance/contraindications

Providers must document prior trials, inadequate response, intolerance, or contraindications to prerequisite Step 1/Step 2 agents in the prior authorization request; receipt of samples does not satisfy criteria.

Definitions

Step 1 Medications: Medications that do not require Step Therapy, are automatically covered, and do not require prior authorization.

Step 2 Medications: Usually brand name medications that do not require Step Therapy, are automatically covered, and do not require prior authorization.

Step 3 Medications: Usually brand name medications that require Step Therapy; initiating these often requires prior authorization and documentation of prior failures, intolerance, or contraindications to required Step 1/Step 2 agents.

Applicable Codes

Coverage Policy Numbermixed

1801	Cigna Coverage Policy Number for Step Therapy - Standard and Performance Prescription Drug Lists

Background & Rationale

Policy rationale and scope: This policy defines a structured step therapy approach for employer group Standard and Performance Prescription Drug Lists to promote clinically appropriate sequencing of therapies and to support medical necessity determinations. The overarching coverage rule is that Cigna approves coverage for brand name drugs as medically necessary when there is documented failure, inadequate response, contraindication, or intolerance to the number of required Step 1 and/or Step 2 drugs specified by the plan.

Step structure and authorization requirements: Step 1 and Step 2 medications are generally covered without prior authorization. Step 3 medications generally require step therapy and prior authorization when the prescriber seeks to initiate a Step 3 product; authorization requires documentation of prior trials, inadequate response, intolerance, or contraindication to prerequisite Step 1/Step 2 agents as specified by the applicable plan (Complete, Essential, Limited). The policy further indicates that dosage, frequency, duration, and site of care should be clinically appropriate and supported by evidence-based literature, and that receipt of sample product does not satisfy trial requirements.

Exceptions and stabilized patient guidance: The policy provides class-specific exceptions and allows exceptions when an individual is not a candidate for step therapy (for example, a stabilized condition where therapeutic interchange is inappropriate). Examples in the policy include: diabetes metformin-step exceptions (approve Farxiga or Jardiance for specified contraindications or clinical situations), an exception to Eucrisa Step Therapy when the patient is < 2 years of age, an exception for Lotemax ophthalmic ointment when the patient has an allergy to benzalkonium chloride, and exceptions when the patient is currently taking certain Carbidopa/Levodopa products (e.g., Crexont or Rytary).

Clinical evidence:

Revision History

2026-03-01revisedLatest

Updated the Auvelity requirement and removed Prozac Weekly and Sarafem.

2026-01-01added

Added Auvelity as an Antidepressant Step 3 Medication.

2025-07-01revised

Clarified Anti-Parkinsonism Drugs step therapy requirements apply to MAO-B inhibitors and added new step therapy requirements for Carbidopa and Levodopa Products Crexont and Rytary.

Policy Summary

PayerCigna

PolicyStep Therapy - Standard and Performance Prescription Drug Lists (Employer Group Plans)

Policy CodePolicy 1801

Change TypeMultiple revisions (removals, additions, clarifications)

Effective DateMar 1, 2026

Next Review Date

On This Page

When coverage is available and medically necessary, dosing and site should be adjusted based on severity and prior response.

Plan-specific Step Requirements and Exceptions

Plan-level step counts and applicability vary by plan (Complete, Essential, Limited); follow the required counts per drug class or note when a plan does not use a class.

threshold":"","note":"Not all plans will use all Step Therapy classes.","children":[]}]}]

HFpEF: If patient has heart failure with preserved ejection fraction (HFpEF), approve Farxiga or Jardiance.

Chronic kidney disease: If patient has chronic kidney disease, approve Farxiga or Jardiance.

ASCVD or ≥2 CVD risk factors: If patient has atherosclerotic cardiovascular disease or, per prescriber, at least two risk factors for cardiovascular disease, approve Farxiga or Jardiance.

Non-Steroidal Topical exception: Exception to Eucrisa Step Therapy: patient is < 2 years of age.

Ophthalmic Corticosteroids exception: Exception to Lotemax ophthalmic ointment Step Therapy when patient has allergy to benzalkonium chloride.

Anti-Parkinsonism Carbidopa/Levodopa Products exceptions: An exception to Step Therapy will be provided when the patient is currently taking Crexont capsules or Rytary.

Policy added Crexont and Rytary as Step 3 and specifies exception for patients currently taking these products.

General exception: An exception will be provided when an individual is not a candidate for Step Therapy (e.g., stabilized condition where therapeutic interchange is inappropriate).

Receipt of sample product does not satisfy the prior therapy requirement for Step Therapy or prior authorization requests.

Step Therapy

Plan-specific step count adherence

Providers must follow Complete/Essential/Limited plan-specific required numbers of Step 1 agents (e.g., Complete/Essential often require 1-3 Step 1 agents depending on class); some plans may not use all Step Therapy classes.

Complete, Essential, and Limited plans have different step-count requirements (examples: Complete/Essential commonly require one to three Step 1 agents depending on drug class).
The required number of Step 1 agents varies by therapeutic class (see class-specific listings such as Diabetes Care, Fibrates, Ophthalmic Corticosteroids).

2025-07-01removed

Removed Benicar, Benicar HCT, Caplyta, Celebrex, Diovan, Diovan HCT, Rexulti, Vraylar, and Vytorin from the policy; added a new Ophthalmic Corticosteroids section with Inveltys and Lotemax products as Step 3 and added Zoryve to Non-Steroidal Topical as Step 3.

2025-01-15revised

Clarified Anti-Parkinsonism Drugs step therapy requirements apply to MAO-B inhibitors and added new step therapy requirements for Carbidopa and Levodopa Products Crexont and Rytary.

2025-01-01removed

Removed Aciphex, Altace, Avapro, Cozaar, Fanapt, and Zestril from the policy.