ModifiedCignaPolicy 1802

Step therapy requirements for prescription drugs

Defines Cigna's step therapy framework for multiple drug classes and the circumstances under which brand-name drugs are approved after failure/intolerance of required step agents; applies to health benefit plans administered by Cigna Companies and affects prescribers and prior authorization reviewers.

Policy Summary

PayerCigna

PolicyStep therapy requirements for prescription drugs

Policy CodePolicy 1802

Change TypeMultiple material revisions (removals and relocations)

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit prior authorization for Step 3 or brand agents and document failure, intolerance, or contraindication to required Step 1/Step 2 agents as specified by plan.

SourceLink

POLICY UPDATE CHANGES

Removed Fanapt, Jentadueto, Jentadueto XR, and Tradjenta from the policy, effective 1/1/2025.

Clarified the current Anti-Parkinsonism Drugs step therapy requirements apply to Monoamine Oxidase Type B (MAO-B) Inhibitors and added new step therapy requirements for Carbidopa and Levodopa products Crexont and Rytary.

Removed Celebrex from the policy, effective 7/1/2025, and added Zoryve 0.15% cream as a Step 3 Medication to the Non-Steroidal Topical section.

Removed Actonel, Adderall, Evekeo, Fetzima and Invega as Step 3 Medications.

Removed the Antidepressants section.

Removed the Non-Steroidal Topical therapeutic category and relocated it to a new policy, Topical Agents for Atopic Dermatitis Step Therapy Policy (ST005).

04/01/2026policy effective date

1–3Step levels

Complete/Essential/Limited

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Coverage Criteria

General Step Therapy Coverage Criteria

Covered when ALL of the following are met

General approval conditions: Brand name drugs are approved when there is documented failure, inadequate response, contraindication per FDA label, or intolerance to the number of Step 1 and/or Step 2 drugs required for the plan or as otherwise specified in the tables.documented failure/intolerance/contraindication

Applies per drug class tables; exceptions allowed as noted.

Diabetes (metformin requirement exceptions)

Exceptions to metformin Step requirements — approve SGLT2 agents if any one of the following is met

Metformin exceptions: 1) The patient will be initiating dual therapy with metformin AND Farxiga or Jardiance; 2) The patient has a contraindication to metformin per prescriber; 3) Heart failure with reduced ejection fraction; 4) Heart failure with preserved ejection fraction; 5) Chronic kidney disease; 6) Atherosclerotic cardiovascular disease or, per the prescriber, the patient has at least two cardiovascular risk factors.one of listed conditions

Metformin step requirement applies to new starts only.

Plan-specific Step Therapy Criteria

Covered when plan-specific step therapy prerequisites are met

Complete Plan requirements: Medications placed at Step 2 or Step 3 for the Complete Plan require the specified number of Step 1 agent trials as indicated (for many entries: 'Complete Plan: Requires ONE Step 1'; topical inflammatory entries may require three Step 1 agents).

See plan-specific tables for exact required counts by medication class.

Essential Plan requirements: Essential Plan commonly requires ONE or TWO Step 1 agent trials depending on the medication and step placement (e.g., some entries specify 'Essential Plan: Requires TWO Step 1 agents').

See plan-specific tables for exact required counts by medication class.

Limited Plan requirements: Limited Plan is frequently marked N/A for many categories, indicating coverage may not be available under Limited Plan for those items unless otherwise specified.

See plan-specific tables for N/A entries.

Topical agent potency mapping

Covered topical agents are categorized by potency and specific active ingredients/brands are listed under each potency classification

Very High Potency agents: Includes clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinonide 0.1%, betamethasone dipropionate augmented 0.05% and brand examples such as Temovate and Ultravate; mapped to Topical Inflammatory, Very High Potency.

See topical agent listings in policy.

High Potency agents: Includes amcinonide 0.1%, betamethasone dipropionate 0.05% ointment, desoximetasone formulations, fluocinonide 0.05% and brand examples such as Topicort 0.05% gel/ointment; mapped to Topical Inflammatory, High Potency.

See topical agent listings in policy.

Medium Potency agents: Includes betamethasone dipropionate 0.05% cream/lotion/spray, betamethasone valerate 0.1% cream/foam, fluticasone propionate 0.005% formulations, mometasone and triamcinolone acetonide low–medium strengths; mapped to Topical Inflammatory, Medium Potency.

See topical agent listings in policy.

This Coverage Policy provides guidance for health benefit plans administered by Cigna Companies but does not supersede the terms of a customer’s specific benefit plan document. In the event of any conflict between this Coverage Policy and a customer’s benefit plan document (for example, Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description), the customer’s benefit plan document always supersedes the Coverage Policy. Coverage determinations must consider the applicable benefit plan terms in effect on the date of service, any applicable laws/regulations, relevant collateral materials including Coverage Policies, and the individual facts of the request.

Selected revisions to this policy removed or relocated specific therapeutic categories and products. Notable changes include removal of Fanapt, Jentadueto, Jentadueto XR, Tradjenta, Actonel, Adderall, Evekeo, Fetzima, Invega, Celebrex and removal of the Antidepressants section; the Non-Steroidal Topical therapeutic category was relocated to a new policy (ST005) and Anti-Parkinsonism Drugs (Carbidopa/Levodopa products) were relocated to a new Parkinson’s Disease policy (ST006). These removals and relocations are effective on the dates specified in the revision history.

Reimbursement will not be provided for services billed for conditions or diagnoses that are not covered under this Coverage Policy. Claims submitted without a covered diagnosis or procedure code as required by the applicable benefit plan and this Coverage Policy will be denied as not covered.

Entries marked “N/A” under the Limited Plan indicate that those medications or step placements are not covered under the Limited Plan unless otherwise specified. Where Limited Plan cells display N/A for a category, coverage under that plan should be assumed to be unavailable for those items unless the plan document or an exception indicates otherwise.

Coding

No specific CPT/HCPCS/ICD-10/NDC codes listed in this partmixed

No codes listed

Metformin step requirement — applies to new starts only

ThresholdMetformin step requirement applies to new starts only.

Applies toType 2 Diabetes therapy prior-step rule for SGLT2 and other non-metformin agents.

ImplicationFor patients already on metformin, the step requirement does not restrict initiation of SGLT2 agents based solely on prior metformin use; the rule targets new treatment starts.

Provider Actions and Requirements

Prior Authorization

Prior Authorization for Step 3 / Brand Agents

Step 3 medications and certain brand agents require prior authorization. If the prescriber determines treatment should begin with a Step 3 agent, a request for authorization must be submitted and approved before coverage is provided for those agents.

Step 3 (usually brand) agents require prior authorization when plan step therapy places them at a higher step.
Requests to start therapy on a Step 3 agent must include clinical justification and prior-agent history as applicable.

Step Therapy

Step Therapy Prior Authorization

Prior authorization is required when the requested agent is positioned at a higher step than plan-specified prior-step agents and those prior-step agents have not been tried, unless an exception applies (see step therapy exceptions).

Where the plan table indicates 'Requires ONE/TWO/THREE Step 1' (or Step 2) agents, documentation of prior use of those specified number of agents is required.
An exception to step therapy may be granted for individuals not candidates for required prior agents (for example, stabilized on a current therapy where switching is inappropriate) or when contraindication/intolerance is documented.

Background

Step therapy is implemented across employer group plans using a Prescription Drug List that groups medications into Step 1–Step 3 tiers. Step 1 agents are generally automatically covered (no prior authorization), while Step 3 medications typically require prior authorization and documented failure, inadequate response, contraindication, or intolerance to the required number of Step 1 and/or Step 2 agents. Exceptions to step therapy may be granted for documented contraindications, intolerances, or other clinically appropriate reasons; plan-specific requirements (Complete, Essential, Limited) determine the number of prior-step trials needed.

Definitions

Step 1 / Step 2 / Step 3 — Step Therapy definitions

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

Step 2Usually brand-name medications; these medications do not require Step Therapy, are automatically covered, and do not require prior authorization (per resource guidance).

Step 3Usually brand-name medications that require Step Therapy; if treatment should begin with a Step 3 agent, a request for authorization must be submitted and approved.

Exception to Step Therapy — when an exception may be provided

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

Diabetes-specific exceptions

Initial Therapy (Step 1) Criteria

Initial therapy (Step 1)

Step 1 agents are generally automatically covered and do not require prior authorization.

Step 1 coverage: Step 1 medications do not require Step Therapy and are automatically covered for plans that designate them as Step 1.N/A

Applies per class and plan (Complete/Essential/Limited).

Initial therapy (Step 1 prerequisites)

Step 1 agent requirements

Step 1 trials: Complete and Essential plans commonly require trials of specified Step 1 agents before higher-step medications are authorized (examples: 'Complete Plan: Requires ONE Step 1', 'Essential Plan: Requires TWO Step 1 agents' for certain classes such as Topical Inflammatory).

Providers must document prior use of required Step 1/Step 2 agents where plan-specific step requirements specify the number of trials.

Step Therapy Details by Class and Plan

Drug class	Complete Plan	Essential Plan	Limited Plan
Anti-Parkinsonism Drugs (MAO-B inhibitors)
Requires ONE Step 1 agent
N/A
N/A
Anti-Parkinsonism Drugs (Carbidopa and Levodopa products) - Crexont, Rytary
Requires ONE Step 1 agent
Requires ONE Step 1 agent
N/A
Atypical Antipsychotic Agents
Requires ONE Step 1 agent
Requires ONE Step 1 agent
N/A
Diabetes Care (metformin / SGLT2s)
Requires ONE Step 1 agent
Requires ONE Step 1 agent
N/A
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) — Topical Inflammatory
Complete Plan: Requires THREE Step 1 agents
Essential Plan: Requires THREE Step 1 agents
N/A
Inhaled Corticosteroid (ICS) with LABA
Requires ONE Step 1 agent
Requires ONE Step 1 agent
N/A

Requirement	Complete Plan prior trials	Essential Plan prior trials	Limited Plan prior trials / notes
Prior trial of Step 1 agents before coverage of Step 2 or Step 3 medications
Requires documented failure, inadequate response, contraindication, or intolerance to the specified number of Step 1 (and Step 2 if applicable) agents; e.g., many entries: 'Requires ONE Step 1'
Commonly requires ONE or TWO Step 1 agent trials depending on medication; some entries specify 'Requires TWO Step 1 agents'
Limited Plan frequently listed as 'N/A' for many categories indicating noncoverage or different handling; where N/A appears coverage may not be available
Metformin step requirement (applies to new starts only): exceptions allow SGLT2 agents if one listed condition met (dual therapy initiation, contraindication to metformin, HF reduced/preserved EF, CKD, ASCVD or ≥2 CV risk factors)
Complete Plan: Requires ONE Step 1 agent prior to Step 2/3 diabetes agents (per Diabetes Care table)
Essential Plan: Requires ONE Step 1 agent prior to Step 2/3 diabetes agents; some classes require TWO Step 1 agents as noted (e.g., certain NSAID/Topical entries)
Limited Plan: N/A for diabetes and many other classes — Limited Plan entries marked N/A indicate lack of coverage under Limited Plan
Exceptions and revision notes
An exception to Step Therapy criteria will be provided when an individual is not a candidate for Step Therapy (e.g., stabilized condition) or when metformin exceptions apply; recent revisions removed/relocated certain categories and products (see Revision Details)