CurrentFidelis CarePolicy N/A

2026_St_6T_Basic_Mapd

Defines step therapy coverage requirements for multiple branded products (Exxua, Fanapt, Auvelity, Raldesy and others) across several drug groups. Specifies which Step 1 and Step 2 agents count toward prerequisite trials, trial duration/measure (>=1-day supply in prior 180 days), exceptions (suicidal ideation, current or prior use), and product lists affected.

Policy Summary

PayerFidelis Care

Policy2026_St_6T_Basic_Mapd

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must document prior trials of required Step 1 (or Step 1/Step 2 where specified) drugs showing at least a 1-day supply in the prior 180 days to meet step therapy requirements for Exxua, Fanapt, Auvelity, and Raldesy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

4Distinct branded products with specific step criteria (Exxua, Fanapt, Auvelity, Raldesy)

3Common exception types allowed (suicidal ideation, current use, prior use)

>=1-dayMinimum prior trial supply required

Coverage Summary

Defines step therapy coverage requirements for multiple branded products (Exxua, Fanapt, Auvelity, Raldesy and others). Coverage status: covered with criteria. Step therapy applies to each branded product and their related product groups (e.g., Exxua, Fanapt, Auvelity, Raldesy), with specified Step 1 and Step 2 agents and a trial rule of at least a 1-day supply in the prior 180 days to meet prerequisites. Exceptions that permit approval without required trials include documented suicidal ideation or current/prior use of the requested product.

Exxua (brexanolone oral) Step Therapy Criteria

Coverage will be provided when ONE of the following is met:

ANY of the following

Patient has tried one Step 1 drug (at least a 1-day supply in the prior 180 days).>=1-day supply in prior 180 days
Step 1 drugs include Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, or Venlafaxine IR/ER.
Patient has suicidal ideation and therefore may be approved without trial of prerequisite drugs.
Approve Exxua if the patient has suicidal ideation without a trial of prerequisite drugs.
Patient is currently taking Exxua or has taken Exxua in the past.
Current or prior use qualifies for approval.

Products affected - Exxua Step 1 (antidepressant oral products)NDC|mixedCovered

bupropion HCl SR 100 mg tablet	12 hr sustained-release
bupropion HCl SR 150 mg tablet	12 hr sustained-release
bupropion HCl SR 200 mg tablet	12 hr sustained-release
bupropion HCl XL 150 mg 24 hr tablet	extended release
bupropion HCl XL 300 mg 24 hr tablet	extended release
citalopram 10 mg tablet
citalopram 10 mg/5 mL oral solution
citalopram 20 mg tablet
citalopram 40 mg tablet
duloxetine 20 mg capsule	delayed release

1–10 of 18

1/2

Products affected - Exxua Step 2 (Exxua formulations)NDC|mixedCovered

Exxua 18.2 mg (32 tabs) tablet	ER 24 hr dose pack
Exxua 18.2 mg tablet	extended release
Exxua 36.3 mg tablet	extended release
Exxua 54.5 mg tablet	extended release
Exxua 72.6 mg tablet	extended release

Fanapt (iloperidone) Step Therapy Criteria

Coverage will be provided when ONE of the following is met:

ANY of the following

Patient has tried two Step 1 drugs (each at least a 1-day supply in the prior 180 days).each >=1-day supply in prior 180 days
Step 1 drugs include oral Aripiprazole, Asenapine Maleate, Brexpiprazole, Cariprazine HCl, Lumateperone Tosylate, Lurasidone HCl, Olanzapine, Paliperidone, Quetiapine Fumarate, Risperidone, Xanomeline/Trospium Chloride, or Ziprasidone HCl. A trial of the brand name equivalent of a generic step 1 product will also count.
Patient is currently taking Fanapt or has taken Fanapt in the past.
Current or prior use qualifies for approval.

Products affected - Antipsychotics (Fanapt-related Step 1 list)NDC|mixedCovered

aripiprazole 1 mg/mL oral solution
aripiprazole 10 mg disintegrating tablet
aripiprazole 10 mg tablet
aripiprazole 15 mg disintegrating tablet
aripiprazole 15 mg tablet
aripiprazole 2 mg tablet
aripiprazole 20 mg tablet
aripiprazole 30 mg tablet
aripiprazole 5 mg tablet
asenapine 10 mg sublingual tablet

1–10 of 56

1/6

Products affected - Fanapt Step 2NDC|mixedCovered

Fanapt 1 mg tablet
Fanapt 2 mg tablet
Fanapt 4 mg tablet
Fanapt 6 mg tablet
Fanapt 8 mg tablet
Fanapt 10 mg tablet
Fanapt 12 mg tablet
Fanapt Titration Pack A	1 mg (2)-2 mg (2)-4 mg (2)-6 mg (2) tablets
Fanapt Titration Pack B	1 mg (6)-2 mg (2)-6 mg (2)-8 mg (2) tablets
Fanapt Titration Pack C	1 mg (4)-2 mg (2)-6 mg (2) tablets

Auvelity (dextromethorphan-bupropion) Step Therapy Criteria

Products affected - Auvelity Step 1 (selected antidepressants/bupropion products)NDC|mixedCovered

bupropion HCl 100 mg tablet
bupropion HCl 75 mg tablet
bupropion HCl SR 100 mg tablet	12 hr sustained-release
bupropion HCl SR 150 mg tablet	12 hr sustained-release
bupropion HCl SR 200 mg tablet	12 hr sustained-release
bupropion HCl XL 150 mg	24 hr extended release
bupropion HCl XL 300 mg	24 hr extended release
citalopram 10 mg tablet
citalopram 10 mg/5 mL oral solution
citalopram 20 mg tablet

1–10 of 26

1/3

Products affected - Auvelity Step 2 (other antidepressants)NDC|mixedCovered

Auvelity 45 mg-105 mg tablet	extended release
fluvoxamine 25 mg tablet
fluvoxamine 50 mg tablet
fluvoxamine 100 mg tablet
nefazodone 50 mg tablet
nefazodone 100 mg tablet
nefazodone 150 mg tablet
nefazodone 200 mg tablet
nefazodone 250 mg tablet
paroxetine 10 mg tablet

1–10 of 31

1/4

Raldesy (trazodone oral solution) Step Therapy Criteria

Coverage will be provided when ONE of the following is met:

ANY of the following

Patient has tried a tablet dosage form of generic trazodone (at least a 1-day supply in the prior 180 days).>=1-day supply in prior 180 days
Generic trazodone tablet formulations count as Step 1 trial.
Patient has difficulty swallowing tablets or cannot swallow tablets.
Approve Raldesy if patient cannot swallow tablets; oral solution may be approved when tablets cannot be taken.
Patient is currently taking Raldesy or has taken Raldesy in the past.
Current or prior use qualifies for approval.

Products affected - Raldesy / TrazodoneNDC|mixedCovered

trazodone 50 mg tablet
trazodone 100 mg tablet
trazodone 150 mg tablet
Raldesy 10 mg/mL oral solution

Provider Actions

Prior Authorization

Step therapy prerequisite trial documentation

Provider must document prior trials of required Step 1 (or Step 1/Step 2 where specified) drugs showing at least a 1-day supply in the prior 180 days to meet step therapy requirements for Exxua, Fanapt, Auvelity, and Raldesy.

Prior trial must show at least a 1-day supply in the prior 180 days.
Applies to Exxua, Fanapt, Auvelity, and Raldesy (see respective Step 1/Step 2 product lists).

Documentation Required

Exceptions documentation (suicidal ideation or current/prior use)

Provider must document suicidal ideation, current use, or prior use of the requested product to qualify for exception-based approval.

Examples of acceptable documentation: record of suicidal ideation (supports approval without prerequisite trials).
Examples of acceptable documentation: medication history showing current use of the requested product.
Examples of acceptable documentation: medication history showing prior use of the requested product.

Applicable Codes

Products affected - Exxua Step 1 (antidepressant oral products)NDC|mixedCovered

bupropion HCl SR 100 mg tablet	12 hr sustained-release
bupropion HCl SR 150 mg tablet	12 hr sustained-release
bupropion HCl SR 200 mg tablet	12 hr sustained-release
bupropion HCl XL 150 mg 24 hr tablet	extended release
bupropion HCl XL 300 mg 24 hr tablet	extended release
citalopram 10 mg tablet
citalopram 10 mg/5 mL oral solution
citalopram 20 mg tablet
citalopram 40 mg tablet
duloxetine 20 mg capsule	delayed release

1–10 of 18

1/2

Products affected - Exxua Step 2 (Exxua formulations)NDC|mixedCovered

Exxua 18.2 mg (32 tabs) tablet	ER 24 hr dose pack
Exxua 18.2 mg tablet	extended release
Exxua 36.3 mg tablet	extended release
Exxua 54.5 mg tablet	extended release
Exxua 72.6 mg tablet	extended release

Products affected - Antipsychotics (Fanapt-related Step 1 list)NDC|mixedCovered

aripiprazole 1 mg/mL oral solution
aripiprazole 10 mg disintegrating tablet
aripiprazole 10 mg tablet
aripiprazole 15 mg disintegrating tablet
aripiprazole 15 mg tablet
aripiprazole 2 mg tablet
aripiprazole 20 mg tablet
aripiprazole 30 mg tablet
aripiprazole 5 mg tablet
asenapine 10 mg sublingual tablet

1–10 of 56

1/6

Products affected - Fanapt Step 2NDC|mixedCovered

Fanapt 1 mg tablet
Fanapt 2 mg tablet
Fanapt 4 mg tablet
Fanapt 6 mg tablet
Fanapt 8 mg tablet
Fanapt 10 mg tablet
Fanapt 12 mg tablet
Fanapt Titration Pack A	1 mg (2)-2 mg (2)-4 mg (2)-6 mg (2) tablets
Fanapt Titration Pack B	1 mg (6)-2 mg (2)-6 mg (2)-8 mg (2) tablets
Fanapt Titration Pack C	1 mg (4)-2 mg (2)-6 mg (2) tablets

Products affected - Auvelity Step 1 (selected antidepressants/bupropion products)NDC|mixedCovered

bupropion HCl 100 mg tablet
bupropion HCl 75 mg tablet
bupropion HCl SR 100 mg tablet	12 hr sustained-release
bupropion HCl SR 150 mg tablet	12 hr sustained-release
bupropion HCl SR 200 mg tablet	12 hr sustained-release
bupropion HCl XL 150 mg	24 hr extended release
bupropion HCl XL 300 mg	24 hr extended release
citalopram 10 mg tablet
citalopram 10 mg/5 mL oral solution
citalopram 20 mg tablet

1–10 of 26

1/3

Products affected - Auvelity Step 2 (other antidepressants)NDC|mixedCovered

Auvelity 45 mg-105 mg tablet	extended release
fluvoxamine 25 mg tablet
fluvoxamine 50 mg tablet
fluvoxamine 100 mg tablet
nefazodone 50 mg tablet
nefazodone 100 mg tablet
nefazodone 150 mg tablet
nefazodone 200 mg tablet
nefazodone 250 mg tablet
paroxetine 10 mg tablet

1–10 of 31

1/4

Products affected - Raldesy / TrazodoneNDC|mixedCovered

trazodone 50 mg tablet
trazodone 100 mg tablet
trazodone 150 mg tablet
Raldesy 10 mg/mL oral solution

Background

This policy enumerates step therapy requirements across multiple therapeutic classes (antidepressants and antipsychotics). For each branded product the policy lists which agents count as Step 1 (the prerequisite generics/alternative agents) and which agents are Step 2 (the branded target or next-line products). Examples: Exxua Step 1 includes generic SSRIs/SNRIs and bupropion SR/XL with Exxua formulations as Step 2; Fanapt Step 1 includes multiple oral antipsychotics with Fanapt as Step 2; Auvelity requires trials of a generic SSRI or SNRI plus bupropion as Step 1 with Auvelity as Step 2; Raldesy requires a trial of tablet trazodone as Step 1 with Raldesy oral solution as Step 2. Coverage is granted when the specified Step 1 trial(s) are documented (each trial = at least a 1-day supply in the prior 180 days). The policy also permits approval without prior trials when the patient has documented suicidal ideation or when the patient is currently taking or has previously taken the requested product.

Step 1 drug: Drugs listed under the Step 1 section for each product; a trial (>= 1-day supply in the prior 180 days) counts toward prerequisite.

Step 2 drug: Drugs listed under the Step 2 section; may be the target branded product or next-line agents as specified for each policy.

Clinical Evidence

No formal evidence entries are provided in the brief. The policy bases its step lists on therapeutic class groupings (e.g., generic SSRIs/SNRIs and bupropion for antidepressants; a set of oral antipsychotics for Fanapt) and states exception rationales (suicidal ideation, current use, prior use) that allow approval without prerequisite trials. The brief does not include clinical trial data or statistics.

Policy Summary

PayerFidelis Care

Policy2026_St_6T_Basic_Mapd

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

2026_St_6T_Basic_Mapd

Coverage Summary

Exxua (brexanolone oral) Step Therapy Criteria

Fanapt (iloperidone) Step Therapy Criteria

Auvelity (dextromethorphan-bupropion) Step Therapy Criteria

Raldesy (trazodone oral solution) Step Therapy Criteria

Provider Actions

Applicable Codes

Background

Clinical Evidence

Revision History