2026 Step Therapy Criteria — Antidepressants, Antipsychotics (oral), Dextromethorphan/Bupropion, Trazodone
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Step therapy requirements for selected antidepressant, oral antipsychotic, dextromethorphan/bupropion, and trazodone products that govern prior trial requirements and exceptions for Fidelis Care members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Step Therapy Requirements
Antidepressants — Initial Step Therapy
Coverage will be provided when ALL of the following are met:
Counts brand-name equivalent of a generic Step 1 product as meeting requirement
Oral Antipsychotics — Initial Step Therapy
Coverage will be provided when ALL of the following are met:
A trial of the brand name equivalent of a generic step 1 product will also count.
Dextromethorphan/Bupropion (Auvelity) — Initial Step Therapy
Coverage will be provided when ALL of the following are met:
Trazodone — Initial Step Therapy
Coverage will be provided when ALL of the following are met:
No additional criteria text provided in this part.
No explicit clinical exclusions are listed in this section of the policy. The document defines the step requirements and exceptions (including suicidal ideation and prior/current use of Step 2 agents) but does not enumerate any standalone clinical exclusion criteria for the therapies covered here.
There are no explicit exclusions stated for trazodone or Raldesy in this portion of the policy. The policy sets step-trial requirements and exceptions (e.g., inability to swallow tablets, current or prior use of Raldesy) rather than listing specific clinical exclusions.
The policy does not list explicit denials for Step 2 products, but coverage is contingent on meeting the stated step requirements. In practice, a Step 2 product is not approved until the required Step 1 trials are documented (e.g., one Step 1 antidepressant trial for antidepressant Step 2 agents; two Step 1 oral antipsychotic trials for certain antipsychotic Step 2 agents; both a generic SSRI/SNRI and bupropion for Auvelity). Absent documentation of those required prior trials or an applicable exception, the Step 2 product will not meet coverage criteria.
The policy does not explicitly state a separate denial list, but it establishes that Raldesy (the Step 2 trazodone oral solution) requires evidence of a prior tablet trial of generic trazodone (at least a 1-day supply within the prior 180 days) or a recognized exception (difficulty swallowing tablets, or current/prior use of Raldesy). If the prior tablet trial requirement is not met and no exception applies, coverage for the Step 2 oral solution is not supported.
Coding and Look-back Definitions
| trazodone 50 mg tablet | listed tablet strength |
| trazodone 100 mg tablet | listed tablet strength |
| trazodone 150 mg tablet | listed tablet strength |
| >= 1-day supply in prior 180 days | Prior trial look-back requirement for tablet trial |
| Raldesy 10 mg/mL oral solution | oral solution formulation (step 2) |
| Patient cannot swallow tablets OR currently/previously taking Raldesy | Exceptions allowing approval without prior tablet trial |
Provider Actions, Prior Authorization & Documentation
Antidepressants prior authorization — document one Step 1 trial
Prior authorization requires documentation that the patient has tried one Step 1 antidepressant (at least a 1‑day supply within the prior 180 days) before approving the specified Step 2 antidepressant agent. Exceptions include documented suicidal ideation or current/prior use of the Step 2 product.
- Step trial definition: ≥1-day supply in prior 180 days counts as a trial.
- Step 1 drug list includes Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, or Venlafaxine.
Oral antipsychotics prior authorization — document two Step 1 trials
Prior authorization for Step 2 oral antipsychotics requires documentation that two Step 1 oral antipsychotic drugs have been tried (each at least a 1‑day supply within the prior 180 days) before coverage of the Step 2 agent, unless the member is currently taking or has taken the Step 2 agent in the past.
- A trial of the brand‑name equivalent of a generic Step 1 product will count toward the requirement.
- Step 1 product list includes oral formulations such as aripiprazole, lurasidone, quetiapine, olanzapine, risperidone, paliperidone, ziprasidone, etc.
Dextromethorphan/bupropion prior authorization — document SSRI/SNRI + bupropion trial
Prior authorization for Auvelity (dextromethorphan/bupropion) requires documentation that the patient has tried a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply within the prior 180 days), unless the patient has suicidal ideation or is currently/previously taking Auvelity.
- Both classes must be documented (one generic SSRI or SNRI AND bupropion).
- Approve without prior trial for suicidal ideation or current/prior Auvelity use.
Step therapy prior authorization — prior tablet trial for Raldesy
Prior authorization for Raldesy requires documentation that the patient has used a generic trazodone tablet (at least a 1‑day supply within the prior 180 days) before approving Raldesy oral solution, unless the patient cannot swallow tablets or is currently/previously taking Raldesy.
- Acceptable tablet strengths include generic trazodone 50 mg, 100 mg, or 150 mg.
- If patient has difficulty swallowing tablets or is currently/previously on Raldesy, the prior tablet trial is not required.
Antidepressants step logic — one Step 1 drug required
For antidepressant step therapy, one Step 1 drug (from the listed SSRIs/SNRIs or bupropion SR/XL) must be tried (≥1‑day supply within the prior 180 days) before a Step 2 antidepressant will be approved; approval without trial is allowed for suicidal ideation or if the patient is currently/previously taking the Step 2 product.
- Step 1 drug examples: Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Venlafaxine IR/ER.
- A single Step 1 drug trial (≥1‑day supply in prior 180 days) satisfies the prerequisite.
Oral antipsychotics step logic — two Step 1 trials required
For oral antipsychotics, coverage of Step 2 agents requires documentation that two Step 1 oral antipsychotic drugs have each been tried (each at least a 1‑day supply within the prior 180 days); approve Step 2 if the patient is currently or previously taking that Step 2 agent.
- Step 1 oral antipsychotics listed include aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, ziprasidone.
- Trials of brand‑name equivalents of generics count toward the two‑drug requirement.
Dextromethorphan/bupropion step logic — SSRI/SNRI + bupropion required
Auvelity requires a documented trial of a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply within the prior 180 days) before coverage will be approved; exceptions include suicidal ideation or current/prior Auvelity use.
- Documentation must show both classes were tried within the look‑back period.
- Suicidal ideation is an allowed exception to the prerequisite trials.
Trazodone step logic — tablet Step 1 then Raldesy Step 2
Step 1 for trazodone includes generic trazodone tablets (50 mg, 100 mg, or 150 mg); Step 2 is Raldesy 10 mg/mL oral solution. Approval of the Step 2 product requires meeting the Step 1 tablet trial requirement or qualifying for an exception.
- Step 1 tablet strengths explicitly listed: 50 mg (in details), 100 mg, 150 mg.
- Step 2 product: Raldesy 10 mg/mL oral solution.
Step sequence — trazodone tablet trial then Raldesy or exception
Step 1 requires a trial of a generic trazodone tablet (50 mg, 100 mg, or 150 mg) with at least a 1‑day supply within the prior 180 days; Step 2 is Raldesy 10 mg/mL oral solution and may be approved if step criteria are met or an exception (e.g., inability to swallow tablets or current/prior Raldesy use) applies.
- Acceptable evidence of Step 1: dispensing or administration of at least a 1‑day supply of a generic trazodone tablet within prior 180 days.
- Exceptions that permit Step 2 without tablet trial: difficulty swallowing tablets, inability to swallow tablets, or documented current/prior Raldesy use.
Evidence of prior trials or exceptions — provide documentation
Documentation must show evidence of prior Step 1 trials (at least a 1‑day supply within the prior 180 days) for the applicable therapy, or documentation of an approved exception such as suicidal ideation or current/prior use of the Step 2 agent.
- Records should indicate dispensing or administration dates and quantities that demonstrate the ≥1‑day supply within the 180‑day look‑back.
- Accepted exceptions: suicidal ideation or documented current/prior use of the Step 2 agent per each policy section.
Required documentation — prior tablet trial or swallowing exception for Raldesy
For Raldesy prior authorization, include documentation that the patient tried a generic trazodone tablet (≥1‑day supply within the prior 180 days), or document inability/difficulty swallowing tablets, or provide evidence the patient is currently or previously taking Raldesy.
- If using the swallowing‑difficulty exception, include clinical notes documenting the inability to swallow tablets.
- If relying on current/prior Raldesy use, include prior medication records showing Raldesy dispensing or administration.
Antidepressants Step 1 prerequisite — risk of denial if not tried
Coverage will be denied for Step 2 antidepressant agents when the prerequisite Step 1 drug has not been tried as required (a trial is defined as at least a 1‑day supply within the prior 180 days).
- Verify a Step 1 trial (≥1‑day supply in prior 180 days) before submitting prior authorization to avoid denial.
- Exceptions such as suicidal ideation or current/prior Step 2 use must be documented to support approval without Step 1 trial.
Oral antipsychotics Step 1 prerequisite — denial risk without two trials
Coverage may be denied for certain Step 2 oral antipsychotics unless two Step 1 oral antipsychotics have been tried and documented (each at least a 1‑day supply within the prior 180 days).
- Document two distinct Step 1 oral antipsychotic trials within the 180‑day look‑back to meet the requirement.
- Current or prior use of the Step 2 agent (e.g., Fanapt) is an alternative justification for approval and should be documented.
Dextromethorphan/bupropion Step requirement — risk of denial if prerequisites missing
Coverage for Auvelity will be denied unless the patient has tried a generic SSRI or SNRI AND bupropion (each at least a 1‑day supply within the prior 180 days), unless an allowed exception (suicidal ideation or current/prior Auvelity use) is documented.
- Ensure documentation shows both the SSRI/SNRI and bupropion trials within the 180‑day look‑back to avoid automatic denial.
- If invoking the suicidal‑ideation exception, include clinical notes supporting that condition.
Prior tablet trial required — denial risk for Raldesy without tablet trial
Coverage may be denied for Raldesy if the patient has not tried a tablet dosage form of generic trazodone (at least a 1‑day supply within the prior 180 days) and no applicable exception is documented.
- Confirm dispensing or administration of a generic trazodone tablet within the 180‑day look‑back before requesting approval.
- If the patient cannot swallow tablets, include clinical documentation to support the swallowing‑inability exception.
Background
Step therapy is used in this policy to manage utilization and to encourage use of lower-cost or preferred therapies before advancing to Step 2 agents. The document specifies Step 1 product lists and defines a qualifying trial as at least a 1-day supply within the prior 180 days; certain Step 2 agents may be approved without prior trials when exceptions apply (for example, suicidal ideation or documented current/prior use of the Step 2 product). These step requirements and exceptions govern prior authorization decisions and determine when Step 2 products will be covered.
Definitions and Exceptions
Initial Therapy Criteria by Drug Class
Antidepressants initial therapy
Antidepressant initial therapy steps
See Step 1 product list.
Oral antipsychotics initial therapy
Oral antipsychotics initial therapy
See Step 1 product list.
Auvelity initial therapy
Auvelity initial therapy
Suicidal ideation or current/prior use are exceptions.
Trazodone initial therapy
Trazodone initial therapy
No additional criteria provided in this part.
Step 1: Tablet trial
Initial therapy preferred agents
Continuation Therapy and Exceptions
Continuation therapy exceptions
Continuation/allowance for current or prior use of Step 2 agent
Applies to Exxua, Fanapt, Auvelity as specified.
Step Therapy Tables
| Step | Requirement / Description | Coverage Status |
|---|---|---|
| Step 1: Specified Step 1 trials within the prior 180 days (at least a 1-day supply). For antidepressants this is one Step 1 drug (Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, or Venlafaxine IR/ER). For oral antipsychotics this is two Step 1 oral antipsychotic drugs (e.g., aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, or ziprasidone). For Auvelity require a generic SSRI or SNRI AND bupropion (each ≥1-day supply in prior 180 days). | ||
| Step 2: Coverage of Step 2 agents is permitted after required Step 1 trials are documented. Exceptions allow approval of certain Step 2 agents (e.g., Exxua, Auvelity, Fanapt products) without prior trials if the patient has suicidal ideation or is currently taking / previously took the Step 2 agent. |
| Step | Required Trial | Coverage Status |
|---|---|---|
| Trial of trazodone tablet dosage form (50 mg, 100 mg, or 150 mg) — patient must have used a tablet dosage form of generic trazodone for at least a 1-day supply within the prior 180 days. |
| Product | Approval Conditions | Coverage Status |
|---|---|---|
| May be approved after documentation of a prior tablet trial of generic trazodone (≥1-day supply in prior 180 days), or if the patient cannot swallow tablets, or if the patient is currently taking or has previously taken Raldesy. |
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