Currentharvard pilgrim health carePolicy N/A

Step therapy rules for select medications

Defines step-therapy placement and prior authorization conditions for specific outpatient drugs (antidepressants, atypical antipsychotics, inhaled corticosteroids, interferons) for Tufts Medicare Preferred members; affects providers submitting pharmacy claims and prior authorization requests.

Policy Summary

Payerharvard pilgrim health care

PolicyStep therapy rules for select medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionProvide paid pharmacy claim history or physician documentation showing required Step-1 (or Step-2 where specified) fills within the prior 180 days to support Step-2 coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiple levelsstep therapy

180 dayslookback

1–2 requiredprior fills

14+products listed

Coverage Criteria by Therapeutic Group

Antidepressants - Initial (Step-1) and Step-2

Policy Summary

Payerharvard pilgrim health care

PolicyStep therapy rules for select medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionProvide paid pharmacy claim history or physician documentation showing required Step-1 (or Step-2 where specified) fills within the prior 180 days to support Step-2 coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage rules for antidepressant agents

Antidepressant Step-1 coverage: Step-1 agents (bupropion, bupropion SR, bupropion XL, citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine, fluoxetine delayed-release, fluvoxamine, paroxetine, sertraline, venlafaxine and venlafaxine ER) are covered without prior authorization.

Supported by paid claim or provider documentation requirements for Step-2

Antidepressants - Step-2 coverage condition

Antidepressant Step-2 coverage condition: Emsam, Fetzima, and Exxua (and their titration packs where listed) are Step-2; covered only if the member has filled for a Step-1 or Step-2 medication within the previous 180 days as evidenced by a paid claim or physician documentation.180 days

Evidence may be paid claim or physician documentation.

Atypical Antipsychotics - Step-1

Coverage rules for atypical antipsychotics

Atypical antipsychotic Step-1 coverage: Aripiprazole, lurasidone, olanzapine, olanzapine-fluoxetine, quetiapine, risperidone and ziprasidone are on Step-1 and covered without authorization.

Atypical Antipsychotics - Step-2 coverage condition

Atypical antipsychotic Step-2 coverage condition: Asenapine and Fanapt (and their titration packs where listed) are Step-2 and will be covered if the member has filled for one or more Step-1 or Step-2 medications within the previous 180 days as evidenced by a paid claim or physician documentation.180 days

Evidence may be paid claim or physician documentation.

Inhaled Corticosteroids - Step-1

Coverage rules for inhaled corticosteroids

Inhaled corticosteroid Step-1 coverage: QVAR is on Step-1 and covered without authorization.

Inhaled Corticosteroids - Step-2 coverage condition

Inhaled corticosteroid Step-2 coverage condition: Fluticasone products are Step-2 and will be covered if the member has filled for one or more Step-1 medications within the previous 180 days as evidenced by a paid claim or physician documentation.180 days

Evidence may be paid claim or physician documentation.

Interferons - Step-1

Coverage rules for interferon beta products

Interferon Step-1 coverage: Avonex, Betaseron, and Plegridy are on Step-1 and covered without prior authorization.

Interferons - Step-2 coverage condition

Interferon Step-2 coverage condition: Rebif and Rebif Rebidose (and their titration packs where listed) are Step-2 and will be covered if the member has filled for two or more Step-1 medications within the previous 180 days as evidenced by a paid claim or physician documentation.two fills within 180 days

Evidence may be paid claim or physician documentation.

This policy does not list separate exclusions beyond the step-therapy rules. Instead, coverage for a Step-2 product will be denied when the required evidence of prior therapy within the 180-day lookback is not provided. Evidence must be either a paid pharmacy claim showing the required prior fills or physician documentation demonstrating the fills. Specific requirements vary by drug group (for example, most Step-2 products require one or more Step-1/Step-2 fills within 180 days, while interferon Step-2 products require two or more Step-1 fills within 180 days).

Key Coding and Lookback Parameters

Lookback period

Lookback period180 days

Evidence types acceptedPaid pharmacy claim or physician documentation demonstrating fills within the 180-day lookback

Applies toStep-2 coverage determinations across antidepressants, atypical antipsychotics, inhaled corticosteroids, and interferons

Required prior fills for Rebif (interferons)

Required prior fills for Rebif (Rebif Rebidose)Two or more Step-1 medication fills within the previous 180 days

Evidence acceptedPaid claim history or physician documentation showing the two or more Step-1 fills

Step-1 examplesAvonex, Betaseron, Plegridy are the Step-1 interferon products referenced

Prior Authorization, Documentation, and Step Therapy Actions

Prior Authorization

Prior Authorization Required for Step-2 — Evidence of Prior Fills

Step-1 medications are covered without prior authorization. Step-2 medications require evidence of prior therapy (paid claim history or physician documentation) showing fills within the past 180 days before coverage will be approved.

Step-1 examples: bupropion (SR, XL), citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine (including delayed-release), fluvoxamine, paroxetine, sertraline, venlafaxine (and ER)
Step-2 examples (antidepressants): Emsam, Fetzima (includes Fetzima Titration Pack), Exxua
Step-1 antipsychotics: aripiprazole, lurasidone, olanzapine (and olanzapine-fluoxetine), quetiapine, risperidone, ziprasidone
Step-2 antipsychotics: asenapine, Fanapt (includes Fanapt Titration Packs B & C)
Step-1 inhaled corticosteroid: QVAR
Step-2 inhaled corticosteroid: fluticasone (evidence: prior Step-1 fill within 180 days)
Step-1 interferons: Avonex, Betaseron, Plegridy
Step-2 interferons: Rebif and Rebif Rebidose (require two or more prior Step-1 fills within 180 days; includes Rebif Titration Pack and Rebif Rebidose Titration Pack)

Step Therapy

General Step Therapy Rule

General step therapy rule: coverage of a Step-2 medication requires documentation that the member filled for a qualifying Step-1 (or Step-2 where specified) medication within the previous 180 days. Evidence may be a paid pharmacy claim or a physician attestation in the medical record.

Standard lookback period: 180 days from the date of the requested fill
Acceptable evidence: paid pharmacy claim history or physician documentation/attestation
For most Step-2 drugs a single prior Step-1 fill within 180 days is sufficient unless otherwise noted

Documentation Required

Documentation Accepted for Step-2 Approval

Evidence required to support approval of Step-2 drugs: a searchable paid claim showing the qualifying prior fill(s) within 180 days or a physician's documentation indicating medication history supporting the step requirement.

Paid claim should include date of fill and drug name
Physician documentation must specify prior medication name(s) and dates filled
If claim history is not available, include a clear attestation in chart notes

Step Therapy

Class-Specific Step Therapy Requirements

Specific step therapy notes by drug class: antidepressants — Step-1 agents are covered without prior authorization; Step-2 antidepressants (Emsam, Fetzima, Exxua) require evidence of a Step-1 or Step-2 fill within 180 days. Antipsychotics — Step-1 agents covered; Step-2 (asenapine, Fanapt) require one or more Step-1/Step-2 fills within 180 days. Inhaled corticosteroids — QVAR covered; fluticasone requires one prior Step-1 fill within 180 days. Interferons — Avonex, Betaseron, Plegridy covered; Rebif and Rebif Rebidose require two or more prior Step-1 fills within 180 days.

Antidepressants (Step-2): Emsam, Fetzima (and titration pack), Exxua — 1 prior Step-1/Step-2 fill within 180 days
Atypical antipsychotics (Step-2): asenapine, Fanapt (and titration packs) — 1 prior Step-1/Step-2 fill within 180 days
Inhaled corticosteroids (Step-2): fluticasone propionate HFA — 1 prior Step-1 fill within 180 days
Interferons (Step-2): Rebif, Rebif Rebidose (and titration packs) — 2 or more prior Step-1 fills within 180 days

Step-1 Initial Therapy Coverage

Step-1 initial therapy

Step-1 agents are covered without prior authorization for their respective therapeutic groups.

Step-1 coverage: Listed Step-1 products (per group) are covered without prior authorization.

See group-specific lists in document.

Definitions: Step Levels and Terms

Step-1 — preferred agents covered without prior authorization

Antidepressants (Step-1)Bupropion (including SR/XL), citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine (including delayed-release), fluvoxamine, paroxetine, sertraline, venlafaxine (including ER)

Atypical antipsychotics (Step-1)Aripiprazole, lurasidone, olanzapine, olanzapine-fluoxetine, quetiapine, risperidone, ziprasidone

Inhaled corticosteroid (Step-1)QVAR

Interferons (Step-1)Avonex, Betaseron, Plegridy

Step-2 — non-preferred agents requiring prior use evidence within 180 days

Antidepressants (Step-2)Emsam, Fetzima, Exxua — covered only if member has filled for a Step-1 or Step-2 medication within the previous 180 days (paid claim or physician documentation)

Atypical antipsychotics (Step-2)Asenapine, Fanapt — covered if member has filled one or more Step-1 or Step-2 medications within the previous 180 days (paid claim or physician documentation)

Inhaled corticosteroids (Step-2)Fluticasone products — covered if member has filled one or more Step-1 medications within the previous 180 days (paid claim or physician documentation)

Interferons (Step-2)Rebif and Rebif Rebidose — covered if member has filled two or more Step-1 medications within the previous 180 days (paid claim or physician documentation)

Operational Step-Therapy Table

Therapeutic group / product	Required prior fills within 180 days (paid claim or physician documentation)
Antidepressants — Step-2 agents: Emsam, Fetzima, Exxua (and listed titration packs)	At least 1 fill of a Step-1 or Step-2 antidepressant within the previous 180 days (evidence: paid pharmacy claim or physician documentation)
Atypical antipsychotics — Step-2 agents: Asenapine, Fanapt (and listed titration packs)	At least 1 fill of one or more Step-1 or Step-2 antipsychotic medications within the previous 180 days (evidence: paid claim or physician documentation)
Inhaled corticosteroids — Step-2 agents: Fluticasone products (listed formulations)	At least 1 fill of a Step-1 inhaled corticosteroid within the previous 180 days (evidence: paid claim or physician documentation)
Interferons — Step-2 agents: Rebif, Rebif Rebidose (and listed titration packs)	Two or more fills of Step-1 interferon medications within the previous 180 days (evidence: paid claim or physician documentation)

Background and Scope

The policy groups outpatient medications into two step levels. Step-1 lists are formulary-preferred or established agents that are covered without prior authorization. Step-2 includes non-preferred or later-line agents that are covered only when there is documented prior use of the required Step-1 (or where specified, Step-2) agents within the preceding 180 days. Evidence to meet Step-2 requirements may be a paid claim history or physician documentation of the necessary fills; the number of required prior fills differs by drug class (most require one prior fill, while certain interferon products require two prior Step-1 fills).