Currentharvard pilgrim health carePolicy N/A

2026 Step Therapy Medical Necessity Guidelines (selected drugs)

Step therapy requirements for specified outpatient prescription drugs (antidepressants, atypical antipsychotics, inhaled corticosteroids, interferons) for Tufts Health Plan Senior Care Options (HMO-SNP) members; describes which products are Step-1 (no prior authorization) versus Step-2 and the conditions under which Step-2 drugs are covered.

Policy Summary

Payerharvard pilgrim health care

Policy2026 Step Therapy Medical Necessity Guidelines (selected drugs)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionProvide paid pharmacy claim evidence or physician documentation of required Step-1 (or where specified Step-2) medication fills within the previous 180 days to obtain coverage for Step-2 drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=180lookback period (days)

Step-1no auth (Step-1)

Step-2requires prior fills

Tufts HMO-SNPaffected product/line

Step Therapy Coverage Criteria

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Antidepressant Step Therapy

Antidepressants — Covered when the following are met

Antidepressant Step-1 coverage: If medication is one of the listed Step-1 agents (bupropion, bupropion SR/XL, citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine, fluoxetine delayed-release, fluvoxamine, paroxetine, sertraline, venlafaxine, venlafaxine ER), then it is covered without prior authorization.

Antidepressant Step-2 coverage: If medication is one of the Step-2 agents (Emsam, Fetzima, Exxua), then coverage requires 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.

Atypical Antipsychotic Step Therapy

Atypical antipsychotics — Covered when the following are met

Atypical antipsychotic Step-1 coverage: If medication is one of the listed Step-1 agents (aripiprazole, lurasidone, olanzapine, olanzapine-fluoxetine, quetiapine, risperidone, ziprasidone), then it is covered without prior authorization.

Atypical antipsychotic Step-2 coverage: If medication is one of the Step-2 agents (Asenapine, Fanapt and associated titration packs), then coverage requires the member has filled one or more Step-1 or Step-2 medications within the previous 180 days as evidenced by a paid claim or physician documentation.

Inhaled Corticosteroid Step Therapy

Inhaled corticosteroids — Covered when the following are met

Inhaled corticosteroid Step-1 coverage: QVAR is a Step-1 medication and is covered without prior authorization.

Inhaled corticosteroid Step-2 coverage: Fluticasone products (Diskus, HFA) 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.

Interferon Step Therapy

Interferons — Covered when the following are met

Interferon Step-1 coverage: If medication is one of the listed Step-1 agents (Avonex, Betaseron, Plegridy), then it is covered without prior authorization.

Interferon Step-2 coverage: If medication is one of the Step-2 agents (Rebif, Rebif Rebidose), then coverage requires 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.

Step Therapy Drug Lists and Tables

Drug class / requirement	Step	Coverage condition
Antidepressants — Listed Step-1 agents (bupropion, bupropion SR/XL, citalopram, desvenlafaxine ER, duloxetine delayed‑release capsules, escitalopram, fluoxetine (including delayed‑release), fluvoxamine, paroxetine, sertraline, venlafaxine (including ER))
1
Covered without prior authorization.
Antidepressants — Step-2 agents (Emsam, Fetzima, Exxua; includes Fetzima Titration Pack)
2
Covered only if the member has a paid claim or physician documentation showing a fill for a Step-1 or Step-2 medication within the previous 180 days.

Drug / pack	Step	Coverage condition
Asenapine (including sublingual formulations)
2
Will be covered only if the member has filled one or more Step-1 or Step-2 atypical antipsychotic medications within the previous 180 days, as evidenced by a paid claim or physician documentation.
Fanapt and Fanapt titration packs (including listed pack B and C)
2
Will be covered only if the member has filled one or more Step-1 or Step-2 atypical antipsychotic medications within the previous 180 days, as evidenced by a paid claim or physician documentation.

Drug / formulation	Step	Coverage condition
Fluticasone products (e.g., Fluticasone Propionate HFA, Diskus)
2
Will be covered only if the member has filled one or more Step-1 inhaled corticosteroid medications (QVAR) within the previous 180 days, as evidenced by a paid claim or physician documentation.

Drug / pack	Step	Coverage condition
Rebif and Rebif Rebidose (including Rebif Rebidose Titration Pack and Rebif Titration Pack)
2
Will be covered only if the member has filled two or more Step-1 interferon medications (Avonex, Betaseron, Plegridy) within the previous 180 days, as evidenced by a paid claim or physician documentation.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required: Antidepressant Step‑2 Agents

Step therapy: Specific antidepressant Step-1 agents (bupropion, bupropion SR, bupropion XL, citalopram, desvenlafaxine ER, duloxetine delayed‑release capsules, escitalopram, fluoxetine, fluoxetine delayed‑release, fluvoxamine, paroxetine, sertraline, venlafaxine, venlafaxine ER) are on Step‑1 and are covered without prior authorization. Step‑2 antidepressants (for example Emsam, Fetzima, Exxua) require evidence of a paid claim showing the member filled a Step‑1 or Step‑2 medication within the previous 180 days or physician documentation demonstrating prior use. Coverage for Step‑2 antidepressants will be granted only when such documentation is provided.

Affected Step‑2 examples: Emsam; Fetzima; Fetzima Titration Pack; Exxua

Prior Authorization

Prior Authorization Required: Inhaled Corticosteroid Step‑2 Agents

QVAR (beclomethasone) is designated Step‑1 and is covered without prior authorization. Fluticasone products (e.g., Fluticasone Propionate HFA) are Step‑2 and will be covered only if the member has a paid claim for one or more Step‑1 inhaled corticosteroid fills within the previous 180 days or if physician documentation verifies prior use of a Step‑1 product.

Affected Step‑2 example: Fluticasone Propionate HFA

Documentation Required

Acceptable Documentation for Prior Use

Acceptable documentation to demonstrate prior use of required Step‑1 (or Step‑2, when specified) medications includes either: a paid pharmacy claim showing the medication fill within the required look‑back period (typically 180 days), or physician documentation confirming prior use of the required agent(s). Physician documentation should clearly identify the drug name, dates or timeframe of use, and clinical rationale when applicable. The payer may require submission of the claim history or chart notes to validate prior use.

Look‑back period: 180 days for most step therapy requirements unless otherwise specified
Forms of acceptable evidence: paid pharmacy claim or physician documentation (chart note, medication history)
Physician documentation should include drug name, dates of use, and clinical rationale as needed

Terminology

Step-1 — Covered without prior authorization

DefinitionMedications listed as Step-1 are covered without prior authorization as evidenced by the policy's drug lists.

Examples (antidepressants)Bupropion (SR/XL), citalopram, desvenlafaxine ER, duloxetine delayed‑release, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine (incl. ER)

Examples (atypical antipsychotics)Aripiprazole, lurasidone, olanzapine, olanzapine‑fluoxetine, quetiapine, risperidone, ziprasidone

Step-2 — Prior fill requirement for coverage

DefinitionMedications listed as Step-2 require prior evidence of fills of one or more Step-1 (or in specified cases Step-2) medications within the previous 180 days for coverage.

Antidepressant Step-2 examplesEmsam, Fetzima, Exxua — require evidence of a paid claim or physician documentation of a Step-1 or Step-2 fill within the prior 180 days

Atypical antipsychotic Step-2 examplesAsenapine, Fanapt (and titration packs) — require evidence of one or more Step-1 or Step-2 fills within the prior 180 days

Interferon Step-2 exampleRebif and Rebif Rebidose — require evidence the member filled two or more Step-1 medications within the prior 180 days

Background

This policy documents step therapy placements for selected outpatient prescription drug classes used in the Tufts Health Plan Senior Care Options (HMO‑SNP) product line, including antidepressants, atypical antipsychotics, inhaled corticosteroids, and interferons. For each class the policy identifies which agents are Step‑1 (covered without prior authorization) and which are Step‑2 (require prior evidence of fills of Step‑1 or specified Step‑2 agents).

The policy uses a 180‑day lookback period to evaluate prior medication use. Coverage of a Step‑2 medication is contingent on documentation — either a paid pharmacy claim or physician documentation — showing the member filled the required number of Step‑1 (or where specified Step‑2) medications within the previous 180 days.

Examples by drug class: Step‑1 antidepressants (for example bupropion, citalopram, duloxetine, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine) are covered without prior authorization; Step‑2 antidepressants (Emsam, Fetzima, Exxua) require evidence of a Step‑1 or Step‑2 fill in the prior 180 days for coverage. For atypical antipsychotics, listed Step‑1 agents (for example aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone) are covered without authorization; Asenapine and Fanapt (and their titration packs) are Step‑2 and require prior fill evidence of one or more Step‑1 or Step‑2 agents within the previous 180 days. For inhaled corticosteroids, QVAR is Step‑1 and covered without authorization while fluticasone products are Step‑2 and require prior Step‑1 fills within 180 days. For interferons, Avonex, Betaseron, and Plegridy are Step‑1; Rebif and Rebif Rebidose are Step‑2 and require evidence of two or more Step‑1 medication fills within the previous 180 days.

When a paid claim is not available, the policy permits physician documentation to demonstrate prior use within the 180‑day lookback period. Absence of the required documentation or claims may result in denial of coverage for the Step‑2 agent.