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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyExcellus Step Therapy Coverage Update | OpenPayer
    Ask Trek AI about this page
    CurrentExcellus Health Plan IncPolicy N/A

    Step Therapy for Selected Pharmacy Drugs

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    This policy governs coverage and prior authorization requirements for selected Edarbi, Edarbyclor, azilsartan, Nexletol, Nexlizet, penicillamine, trientine, Jardiance, and Synjardy products. Coverage generally requires documented use of specified prerequisite therapies, with limited exceptions.

    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyStep Therapy for Selected Pharmacy Drugs
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNovember 1, 2026
    Next Review DateN/A
    Key ActionComplete the required prerequisite medication trial before requesting the selected drug, or provide applicable exception documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4Drug categories with step-therapy requirements
    365 daysPrescription-profile lookback
    2Required generic ARB trials
    1Required generic statin trial

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1
    Required penicillamine-tablet trial
    1SGLT2 prerequisite trial

    Coverage Criteria

    Edarbi, Edarbyclor, and azilsartan initial therapy

    Covered when the requested Edarbi, Edarbyclor, or azilsartan product has the required prerequisite therapy.

    ARB step requirement: The patient has trialed two select generic angiotensin receptor blockers or ARB combinations.2 trials

    If the required drugs appear in the prescription profile within the last 365 days, additional documentation is not required.

    Nexletol and Nexlizet initial therapy

    Covered when either the generic-statin trial pathway or the statin-intolerance pathway is met.

    Generic statin trial: The patient has trialed one of the following generic statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, or simvastatin.1 trial

    If the required drug appears in the prescription profile within the last 365 days, additional documentation is not required.

    Statin intolerance pathway: Documentation establishes that the patient cannot tolerate statins.Documented intolerance

    This is an alternative to the generic-statin trial.

    Penicillamine and trientine initial therapy

    Covered when the requested penicillamine or trientine capsule product has the required prerequisite therapy.

    Penicillamine tablet step requirement: The patient has trialed penicillamine tablets, generic for Depen.1 trial

    If the required drug appears in the prescription profile within the last 365 days, additional documentation is not required.

    Jardiance and Synjardy initial therapy

    Covered when the prerequisite SGLT2 therapy is met, or when the specified cardiovascular indication exception applies.

    Dapagliflozin-based prerequisite: The patient has trialed brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metformin.1 trial

    If the required drug appears in the prescription profile within the last 365 days, additional documentation is not required.

    Cardiovascular risk-reduction exception: The drug is requested to reduce the risk of cardiovascular death in an adult with type 2 diabetes mellitus and established cardiovascular disease.Adult with type 2 diabetes mellitus and established cardiovascular disease

    The prerequisite trial is not required for this indication.

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required for ARB Products

    Before requesting coverage for Edarbi, Edarbyclor, or an azilsartan product, document the required step-therapy history. Coverage requires trials of two select generic angiotensin receptor blockers (ARBs) or ARB combinations.

    • If the required drugs appear in the prescription profile during the preceding 365 days, additional documentation is not required.
    Prior Authorization

    Prior Authorization Required for Bempedoic Acid

    Before requesting Nexletol or Nexlizet, document either a qualifying generic statin trial or the patient's inability to tolerate statins.

    • Affected products: Nexletol 180 mg tablet and Nexlizet 180 mg/10 mg tablet.
    • Qualifying statins include atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin.

    Policy Background

    This policy applies step therapy to four therapeutic categories: angiotensin receptor blockers and ARB combinations; lipid-lowering therapy; copper-chelating therapy; and SGLT2 inhibitor products, including SGLT2 inhibitor/metformin combinations. Coverage for the selected products generally requires documented use of specified prerequisite therapies, with a statin-intolerance pathway for Nexletol or Nexlizet and a cardiovascular indication exception for Jardiance or Synjardy.

    Initial Therapy Decision Paths

    ARB products

    Coverage requires completion of the following prerequisite therapy before requesting the product.

    Two generic ARB or ARB-combination trials: The patient has completed trials of two select generic angiotensin receptor blockers or ARB combinations.2 trials

    A qualifying trial found in the prescription profile within the last 365 days satisfies the documentation requirement.

    Nexletol and Nexlizet

    Coverage requires either of the following pathways before requesting Nexletol or Nexlizet.

    Generic statin trial: The patient has completed a trial of one of the following generic statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, or simvastatin.1 trial

    Prerequisite Therapy Summary

    Requested productsStep therapy requirementDocumentation or exception
    Edarbi, Edarbyclor, and azilsartan productsTrial of two select generic angiotensin receptor blockers (ARBs) or ARB combinationsIf the required drugs appear in the prescription profile within the last 365 days, additional documentation is not required.
    Requested productsStep therapy requirementDocumentation or exception
    Nexletol or NexlizetTrial of one generic statin: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, or simvastatinAlternatively, provide documentation that the patient cannot tolerate statins. If the required statin appears in the prescription profile within the last 365 days, additional documentation is not required.
    Requested productsStep therapy requirementDocumentation or exception
    Penicillamine capsules or trientine capsulesTrial of penicillamine tablets, generic for DepenIf the required drug appears in the prescription profile within the last 365 days, additional documentation is not required.
    Requested productsStep therapy requirementDocumentation or exception
    Jardiance or SynjardyTrial of brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metforminThe prerequisite trial is not required when the request is to reduce the risk of cardiovascular death in an adult with type 2 diabetes mellitus and established cardiovascular disease. If the required drugs appear in the prescription profile within the last 365 days, additional documentation is not required.
    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyStep Therapy for Selected Pharmacy Drugs
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNovember 1, 2026
    Next Review DateN/A
    Key ActionComplete the required prerequisite medication trial before requesting the selected drug, or provide applicable exception documentation.
    SourceLink
    On This Page
    Coverage CriteriaPrior Authorization and Documentation RequirementsPolicy BackgroundInitial Therapy Decision PathsPrerequisite Therapy Summary
    Step Therapy

    Penicillamine-Tablet Step Therapy

    Coverage of penicillamine capsules or trientine capsules requires a prior trial of penicillamine tablets, the generic for Depen.

    • Affected products: penicillamine 250 mg capsules and trientine 500 mg capsules.
    Prior Authorization

    Prior Authorization Required for SGLT2 Products

    Before requesting Jardiance or Synjardy, document the required dapagliflozin-based prerequisite unless the cardiovascular-risk-reduction exception applies.

    • Qualifying prerequisites are brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metformin.
    Step Therapy

    Two Generic ARB Trials Required

    Document completion of two select generic ARB or ARB-combination trials before requesting Edarbi, Edarbyclor, or an azilsartan product.

    • The two required trials must be documented unless they are present in the preceding 365-day prescription profile.
    Step Therapy

    Generic Statin Trial or Intolerance Required

    For Nexletol or Nexlizet, document a trial of at least one listed generic statin or document that the patient cannot tolerate statins.

    • Listed statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin.
    • When the statin trial appears in the preceding 365-day prescription profile, additional documentation is not required.
    Step Therapy

    Penicillamine Tablet Prerequisite

    For penicillamine or trientine capsules, document a trial of penicillamine tablets, generic for Depen.

    • This prerequisite applies to penicillamine 250 mg capsules and trientine 500 mg capsules.
    • If the prerequisite appears in the preceding 365-day prescription profile, additional documentation is not required.
    Step Therapy

    Dapagliflozin-Based Prerequisite

    For Jardiance or Synjardy, document a trial of an approved dapagliflozin-based prerequisite unless the request is for the qualifying cardiovascular indication.

    • Acceptable prerequisites: brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metformin.
    • If the required drug appears in the preceding 365-day prescription profile, additional documentation is not required.
    Documentation Required

    Document Prior Therapy When Absent

    Review the preceding 365-day prescription profile before requesting coverage. When a required prerequisite therapy is present in that profile, additional documentation of the trial is not required.

    • Applies to the ARB, bempedoic-acid, penicillamine/trientine, and Jardiance/Synjardy requirements.
    • If the prerequisite is absent from the profile, submit documentation of the applicable trial or qualifying exception.
    Documentation Required

    Statin Intolerance Documentation

    For Nexletol or Nexlizet requests based on statin intolerance, document the patient's inability to tolerate statins.

    • A qualifying generic statin trial may be submitted instead of intolerance documentation.
    • The listed statins are atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin.
    Documentation Required

    Cardiovascular Indication Documentation

    For Jardiance or Synjardy, document that the requested therapy is intended to reduce the risk of cardiovascular death in an adult with type 2 diabetes mellitus and established cardiovascular disease when using the prerequisite exception.

    • The prerequisite trial is not required when this qualifying cardiovascular-risk-reduction indication applies.
    Denial Risk

    Two Generic ARB Trials Required

    Coverage of Edarbi, Edarbyclor, and azilsartan products requires completion of two select generic ARB or ARB-combination trials.

    • A request may be denied when the two required generic ARB or ARB-combination trials are not documented and are not present in the preceding 365-day prescription profile.
    Denial Risk

    Statin Trial or Intolerance Required

    Coverage of Nexletol or Nexlizet requires either a qualifying generic statin trial or documentation that the patient cannot tolerate statins.

    • A request may be denied when neither the statin trial nor the statin-intolerance pathway is documented.
    • If the qualifying statin appears in the preceding 365-day prescription profile, additional documentation is not required.
    Denial Risk

    Penicillamine-Tablet Trial Required

    Coverage of penicillamine or trientine capsules requires a documented trial of penicillamine tablets, generic for Depen.

    • A request may be denied when the penicillamine-tablet prerequisite is not documented and is not present in the preceding 365-day prescription profile.
    Denial Risk

    Dapagliflozin-Based Prerequisite Required

    Coverage of Jardiance or Synjardy requires a trial of brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metformin, unless the qualifying cardiovascular-risk-reduction exception applies.

    • The exception applies to adults with type 2 diabetes mellitus and established cardiovascular disease when treatment is requested to reduce the risk of cardiovascular death.
    • A request may be denied when the prerequisite or qualifying exception is not documented and the prerequisite is absent from the preceding 365-day prescription profile.

    A qualifying statin trial found in the prescription profile within the last 365 days requires no additional documentation.

    Statin intolerance: Documentation establishes that the patient cannot tolerate statins.Documented intolerance

    This pathway is an alternative to the generic-statin trial.

    Penicillamine and trientine capsules

    Coverage requires completion of the following prerequisite therapy before requesting penicillamine or trientine capsules.

    Penicillamine tablet trial: The patient has completed a trial of penicillamine tablets, generic for Depen.1 trial

    A qualifying trial found in the prescription profile within the last 365 days requires no additional documentation.

    Jardiance and Synjardy

    Coverage requires the prerequisite therapy unless the specified cardiovascular indication exception applies.

    Dapagliflozin-based prerequisite: The patient has completed a trial of brand Farxiga, brand Xigduo, generic dapagliflozin, or generic dapagliflozin/metformin.1 trial

    A qualifying prerequisite found in the prescription profile within the last 365 days requires no additional documentation.

    Cardiovascular exception: The request is to reduce the risk of cardiovascular death in an adult with type 2 diabetes mellitus and established cardiovascular disease.Specified cardiovascular indication

    The prerequisite trial is not required for this use.