Antidepressants — Step 1 prerequisite

Step 2 antidepressant products require evidence that the member has tried ONE Step 1 antidepressant (at least a 1‑day supply within the prior 180 days). Exxua may be approved without a prior Step 1 trial if the patient has documented suicidal ideation or is currently/previously taking Exxua.

• Acceptable Step 1 agents include listed generics such as bupropion SR/XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, or venlafaxine IR/ER.
• Document at least a 1‑day supply of the Step 1 agent within the prior 180 days to satisfy the prerequisite.

Antipsychotics (oral) — Step 1 prerequisite

Step 2 oral antipsychotic products require documentation that the member has tried TWO Step 1 oral antipsychotic drugs (each at least a 1‑day supply within the prior 180 days). Approve Fanapt if the patient is currently taking Fanapt or has taken Fanapt in the past.

• Step 1 oral antipsychotics include listed agents such as aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, ziprasidone, etc.
• Each Step 1 trial must be at least a 1‑day supply within the prior 180 days.

Dextromethorphan/bupropion — Step prerequisite

Coverage for Auvelity (dextromethorphan/bupropion) requires documentation that the patient tried a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply in the prior 180 days). Auvelity may be approved without prerequisite trials for documented suicidal ideation or if the patient is currently/previously taking Auvelity.

• Acceptable Step 1 agents include listed SSRIs/SNRIs and bupropion formulations (see Step 1 list).
• Record at least a 1‑day supply of each required Step 1 agent within the prior 180 days to meet the prerequisite.

Step therapy prior authorization for Raldesy

Prior authorization for Raldesy requires evidence that step therapy criteria are met: a prior trial of a generic trazodone tablet (50, 100, or 150 mg) with at least a 1‑day supply in the prior 180 days, or documentation of inability to swallow tablets, or current/prior use of Raldesy.

• If a prior tablet trial cannot be documented, provide documentation of swallowing impairment or evidence the member is currently/previously taking Raldesy.
• Tablet strengths listed for Step 1 include 50 mg, 100 mg, and 150 mg.

Antidepressants — Step therapy rules

For antidepressant step therapy, ensure one Step 1 generic antidepressant from the listed agents has been tried (at least a 1‑day supply in the prior 180 days) before requesting Step 2 products. Exxua is an exception and may be approved without the prerequisite for suicidal ideation or documented current/prior Exxua use.

• Step 1 list includes bupropion SR/XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine IR/ER.
• Document the 1‑day supply within 180 days in the medical record or pharmacy history.

Antipsychotics (oral) — Step therapy rules

For oral antipsychotic step therapy, ensure two distinct Step 1 oral antipsychotic trials (each ≥1‑day supply within the prior 180 days) are documented before requesting Step 2 agents; Fanapt may be approved without Step 1 trials if current/prior Fanapt use is documented.

• Step 1 agents include oral formulations of aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, ziprasidone, and others listed.
• Each Step 1 trial must be verifiable as at least a 1‑day supply in the prior 180 days.

Dextromethorphan/bupropion — Step therapy rules

Auvelity Step 1 requires trials of both a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply in the prior 180 days); Step 2 includes Auvelity and other listed agents. Approve Auvelity without prerequisites for suicidal ideation or documented current/prior Auvelity use.

• Confirm pharmacy fill records or provider documentation showing a 1‑day supply for each required agent within 180 days.
• If suicidal ideation is documented, note that prerequisite trials can be bypassed per policy.

Trazodone — Step therapy rules

Trazodone step therapy: Step 1 includes trazodone tablets (100 mg and 150 mg); Step 2 is Raldesy 10 mg/mL oral solution. A prior tablet trial (at least a 1‑day supply in the prior 180 days) is required unless swallowing impairment or prior/current Raldesy use is documented.

• Step 1 tablet strengths include 50 mg (also listed), 100 mg, and 150 mg.
• If unable to swallow tablets, document the clinical reason to support approval of Raldesy without a tablet trial.

Step therapy structure — Raldesy

Step therapy structure for Raldesy is two-tiered: Step 1 requires a trial of a generic trazodone tablet (50, 100, or 150 mg) with at least a 1‑day supply within the prior 180 days; Step 2 is Raldesy oral solution (10 mg/mL) which may be authorized if Step 1 is met or an exception applies (swallowing difficulty or current/prior Raldesy use).

• Record of the tablet trial (≥1‑day supply within 180 days) or documentation of swallowing impairment or prior Raldesy use must be provided for Step 2 approval.
• Tablet strengths enumerated for Step 1: 50 mg, 100 mg, 150 mg.

Antidepressants — documentation of trial

Documented trials must show at least a 1‑day supply of the listed Step 1 drug within the prior 180 days to satisfy prerequisites for Step 2 antidepressant approvals; absence of such documentation may result in denial.

• Record the date, medication name and strength, and evidence of fill or administration to demonstrate the 1‑day supply within 180 days.

Antipsychotics (oral) — documentation required

For Step 2 oral antipsychotic requests, provide documentation that two distinct Step 1 oral antipsychotic drugs were taken (each at least a 1‑day supply within the prior 180 days) or provide evidence of current/past use of the Step 2 product (Fanapt) to qualify for approval.

• Documentation can include pharmacy fill history, medication administration records, or provider notes specifying dates and quantities to demonstrate at least a 1‑day supply within 180 days.

Dextromethorphan/bupropion — documentation required

For Auvelity requests, document that the patient tried a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply in the prior 180 days), or provide documentation of suicidal ideation or current/prior Auvelity use to allow bypass of prerequisites.

• Acceptable evidence includes pharmacy fills, provider chart notes, or medication lists showing the required agents and dates that satisfy the 180‑day lookback.

Required documentation for Raldesy

For Raldesy, provide a record of prior use of a trazodone tablet (at least a 1‑day supply in the last 180 days), or document inability to swallow tablets, or show prior/current use of Raldesy to support approval.

• If relying on swallowing impairment, include clinical notes describing the impairment or a swallow assessment.
• If relying on prior Raldesy use, include prior medication records showing Raldesy dispensing or administration.

Antidepressants — denial risk for missing Step trial

Failure to document that one Step 1 drug was tried (at least a 1‑day supply in the prior 180 days) for antidepressant Step 2 requests may result in denial of coverage.

• Ensure pharmacy fill data or chart notes are submitted with the prior authorization to avoid denial.

Antipsychotics (oral) — denial risk for missing Step trials

Lack of documentation that two Step 1 oral antipsychotic drugs were tried (each at least a 1‑day supply in the prior 180 days) may lead to denial of Step 2 oral antipsychotic coverage; documenting current or prior use of Fanapt is an alternative route to approval.

• Provide fill records or provider documentation for both Step 1 agents to mitigate denial risk.

Dextromethorphan/bupropion — denial risk for missing Step trials

Coverage for Auvelity requires prior trials of a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply in the prior 180 days); absence of these documented trials may result in denial unless suicidal ideation or prior/current Auvelity use is documented.

• Submit documentation of both required trials or clinical justification to avoid denial.

Raldesy — denial risk for missing prior tablet trial

Coverage for Raldesy requires documentation of a prior trial of a tablet dosage form of generic trazodone (at least a 1‑day supply within the prior 180 days); absence of that trial and lack of documentation of an exception (swallowing impairment or prior Raldesy use) may trigger denial.

• Provide prior fill records or clinical documentation of tablet intolerance/swallowing difficulty or prior Raldesy exposure to support approval.