2026 Step Therapy Medical Necessity Guidelines (selected drug classes)
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Step therapy requirements for select outpatient medications (antidepressants, atypical antipsychotics, inhaled corticosteroids, and multiple sclerosis injectables); defines Step‑1 (no prior authorization) and Step‑2 (requires prior fill history) coverage conditions.
No material clinical or coverage changes in this revision.
Step Therapy Coverage Criteria
Antidepressant step therapy
Coverage for antidepressant products in this section follows a two-step hierarchy:
Atypical antipsychotic step therapy
Coverage for atypical antipsychotics in this section follows a two-step hierarchy:
Inhaled corticosteroid step therapy
Coverage for inhaled corticosteroids in this section follows a two-step hierarchy:
Multiple sclerosis injectable step therapy
Coverage for multiple sclerosis injectable disease-modifying therapies follows a two-step hierarchy:
No specific clinical exclusions are listed for the drug classes addressed in this policy. Coverage for Step-2 agents is conditional on documented prior therapy: the member must have evidence of prior fills (paid claim) or physician documentation showing the required Step-1 or Step-2 medication use within a 180-day look-back period in order for Step-2 products to be covered. When paid claims are not available, timely physician documentation demonstrating prior use within the 180-day window is acceptable.
Examples of how this requirement is applied in the covered classes: antidepressant Step-2 products (Emsam, Fetzima, Exxua) require prior Step-1/Step-2 fills or documentation within 180 days; atypical antipsychotic Step-2 products (Asenapine, Fanapt and titration packs) require one or more prior fills or documentation within 180 days; inhaled corticosteroid Step-2 products (Fluticasone Diskus/HFA) require one or more prior Step-1 fills or documentation within 180 days; multiple sclerosis injectable Step-2 products (Rebif, Rebif Rebidose and titration packs) require evidence of two or more Step-1 fills or physician documentation within 180 days.
Operational Parameters and Coding
Provider Requirements and Prior Authorization Rules
Step-2 prior therapy evidence (180-day look-back)
Step-2 agents require evidence the member has filled a qualifying Step-1 or Step-2 medication within the previous 180 days; this must be shown by a paid claim or physician documentation to meet coverage requirements for Step-2 products.
General step therapy rule
Step-1 agents are covered without prior authorization. Step-2 agents will be covered only if the member has the required prior fills or physician documentation within the prior 180 days as specified for each drug class.
Acceptable evidence of prior therapy
Physician documentation may substitute for a paid claim to demonstrate prior use of Step-1 or Step-2 agents within the previous 180 days when paid claims are not available.
- Documentation must show the member filled a qualifying Step-1 or Step-2 medication within the prior 180 days.
Antidepressant Step-2 denial condition
Coverage for Emsam, Fetzima, and Exxua (including titration packs) will be denied unless the member has a paid claim or physician documentation showing a filled Step-1 or Step-2 medication within the prior 180 days.
Atypical antipsychotic Step-2 denial condition
Coverage for Asenapine and Fanapt (including Fanapt titration packs) will be denied unless the member has a paid claim or physician documentation showing a filled Step-1 or Step-2 medication within the prior 180 days.
Inhaled corticosteroid Step-2 denial condition
Coverage for Fluticasone (Diskus or HFA) will be denied unless the member has a paid claim or physician documentation showing a filled Step-1 medication (QVAR) within the prior 180 days.
MS injectable Step-2 denial condition (Rebif)
Coverage for Rebif and Rebif Rebidose (including titration packs) will be denied unless the member has paid claims or physician documentation showing two or more Step-1 medication fills within the prior 180 days.
- Required Step-1 fills = two or more within 180 days.
Background and Scope
This policy defines a two-step step-therapy approach for the outpatient drug classes included. Step-1 agents are considered first-line and are covered without prior authorization. Step-2 agents require documented prior therapy (paid claim) or physician documentation of prior use within the preceding 180 days to be covered.
The policy’s purpose is to manage utilization by ensuring members try preferred, lower-step options before coverage of Step-2 medications. For antidepressants, atypical antipsychotics, and inhaled corticosteroids the requirement is generally one prior Step-1 (or Step-2 when noted) fill within 180 days; for the multiple sclerosis injectable class the Step-2 agents require evidence of two or more prior Step-1 fills within the same 180-day look-back. Physician documentation is an accepted substitute when paid claims are unavailable.
Key Definitions
Step Therapy Operational Rules by Drug Class
| Drug / Pack | Step | Coverage requirement |
|---|---|---|
| Bupropion, bupropion SR, bupropion XL, citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine, fluoxetine delayed-release, fluvoxamine, paroxetine, sertraline, venlafaxine, venlafaxine ER | ||
| Step-1 | ||
| Covered without prior authorization | ||
| Emsam | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of a Step-1 or Step-2 antidepressant within the previous 180 days or provide physician documentation | ||
| Fetzima | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of a Step-1 or Step-2 antidepressant within the previous 180 days or provide physician documentation | ||
| Fetzima Titration Pack | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of a Step-1 or Step-2 antidepressant within the previous 180 days or provide physician documentation | ||
| Exxua | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of a Step-1 or Step-2 antidepressant within the previous 180 days or provide physician documentation |
| Drug / Pack | Step | Coverage requirement |
|---|---|---|
| Aripiprazole, lurasidone, olanzapine, olanzapine-fluoxetine, quetiapine, risperidone, ziprasidone | ||
| Step-1 | ||
| Covered without prior authorization | ||
| Asenapine | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of one or more Step-1 or Step-2 atypical antipsychotics within the previous 180 days or provide physician documentation | ||
| Fanapt | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of one or more Step-1 or Step-2 atypical antipsychotics within the previous 180 days or provide physician documentation | ||
| Fanapt Titration Pack B | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of one or more Step-1 or Step-2 atypical antipsychotics within the previous 180 days or provide physician documentation | ||
| Fanapt Titration Pack C | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of one or more Step-1 or Step-2 atypical antipsychotics within the previous 180 days or provide physician documentation |
| Drug / Pack | Step | Coverage requirement |
|---|---|---|
| QVAR | ||
| Step-1 | ||
| Covered without prior authorization | ||
| Fluticasone Propionate HFA (Fluticasone) | ||
| Step-2 | ||
| Member must have a paid claim showing a fill of one or more Step-1 inhaled corticosteroids within the previous 180 days or provide physician documentation |
| Drug / Pack | Step | Coverage requirement |
|---|---|---|
| Avonex, Betaseron, Plegridy | ||
| Step-1 | ||
| Covered without prior authorization | ||
| Rebif | ||
| Step-2 | ||
| Member must have paid claims showing two or more Step-1 injectable fills within the previous 180 days or provide physician documentation | ||
| Rebif Rebidose | ||
| Step-2 | ||
| Member must have paid claims showing two or more Step-1 injectable fills within the previous 180 days or provide physician documentation | ||
| Rebif Rebidose Titration Pack | ||
| Step-2 | ||
| Member must have paid claims showing two or more Step-1 injectable fills within the previous 180 days or provide physician documentation | ||
| Rebif Titration Pack | ||
| Step-2 | ||
| Member must have paid claims showing two or more Step-1 injectable fills within the previous 180 days or provide physician documentation |
Policy Revision History
Policy effective date established for the '2026 Step Therapy Medical Necessity Guidelines'.
Document titled '2026 Step Therapy Medical Necessity Guidelines'.
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