Currentharvard pilgrim health carePolicy N/A

Tufts Medicare Preferred 2026 Step Therapy Medical Necessity Guidelines

Step therapy requirements for specified drug products under Tufts Medicare Preferred effective June 1, 2026, listing Step-1 and Step-2 medications and the documentation/claim-history needed to approve Step-2 agents.

Policy Summary

Payerharvard pilgrim health care

PolicyTufts Medicare Preferred 2026 Step Therapy Medical Necessity Guidelines

Policy CodePolicy N/A

Change TypeStep therapy designations added

Effective DateJun 1, 2026

Next Review Date

Key ActionTo approve Step-2 agents, provide evidence of paid claim(s) or physician documentation showing fills of required Step-1 (or Step-1/Step-2 as specified) within the prior 180 days; Rebif requires evidence of two or more Step-1 fills.

SourceLink

POLICY UPDATE CHANGES

Tufts Medicare Preferred 2026 Step Therapy Medical Necessity Guidelines effective June 1, 2026 published with Step-1 and Step-2 designations for multiple drug groups.

4Drug groups with step rules in document

180 daysRequired prior-fill lookback period

2Rebif prior Step-1 fills required

What is changing

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Tufts Medicare Preferred 2026 Step Therapy Medical Necessity Guidelines effective June 1, 2026 establish Step designations across multiple drug groups. Certain medications are designated Step-1 and are covered without prior authorization (examples: bupropion, citalopram, aripiprazole, QVAR).

Other medications are designated Step-2 and require evidence of prior medication fills within a 180-day lookback period to be covered. For most Step-2 agents (e.g., Emsam, Exxua, Fetzima, Asenapine, Fanapt, fluticasone products) coverage requires a paid claim or physician documentation showing the member filled required Step-1 (or Step-2 as specified) medications within the previous 180 days.

For Rebif products the requirement is specific: Rebif and Rebif Rebidose (including titration packs) are Step-2 and will be covered only 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.

This bulletin is a material change specifying these Step-1 and Step-2 designations and the associated prior-fill documentation requirements effective 2026-06-01.

Display scope and key thresholds

ScopeStep therapy requirements for specified drug products under Tufts Medicare Preferred effective June 1, 2026 (antidepressants, atypical antipsychotics, inhaled corticosteroids, interferon products)

Prior Fill Lookback (180 days)Member must have filled for required Step-1 or Step-2 medications within the previous 180 days (evidence: paid claim or physician documentation)

Rebif requirement (2 Step-1 fills)Rebif requires evidence of two or more prior Step-1 medication fills within the previous 180 days

Step therapy requirements (criteria)

Step Therapy

Documentation of prior fills for Step-2 approval

Provide evidence of paid claim(s) or physician documentation showing fills of required Step-1 (or Step-1/Step-2 as specified) medications within the prior 180 days to approve Step-2 agents. For Rebif products, documentation must show two or more prior Step-1 fills within the previous 180 days.

Examples of Step-2 agents: Emsam, Exxua, Fetzima, Asenapine, Fanapt, Fluticasone, Rebif
Rebif (and Rebif Rebidose/titration packs) requires evidence of two or more prior Step-1 fills within the previous 180 days

Products and codes affected

Products Affected - Antidepressantsmixed

Emsam	Selegiline transdermal system (product listed as Step-2)
Exxua	Desvenlafaxine product (Step-2)
Exxua Titration Pack	Titration pack for Exxua
Fetzima	Levomilnacipran (Step-2)
Fetzima Titration Pack	Titration pack for Fetzima

Products Affected - Atypical Antipsychoticsmixed

Asenapine Maleate Sl	Asenapine sublingual (Step-2)
Fanapt	Iloperidone (Step-2)
Fanapt Titration Pack A	Titration pack A
Fanapt Titration Pack B	Titration pack B
Fanapt Titration Pack C	Titration pack C

Products Affected - Inhaled Corticosteroidsmixed

Fluticasone Propionate Diskus	Fluticasone Diskus (Step-2)
Fluticasone Propionate Hfa	Fluticasone HFA (Step-2)

Products Affected - Multiple Sclerosis Interferonsmixed

Rebif	Interferon beta-1a (Step-2)
Rebif Rebidose	Rebif Rebidose (Step-2)
Rebif Rebidose Titration Pack	Titration pack
Rebif Titration Pack	Titration pack

Step-1 Drugs Listed in Details (examples)mixedCovered

Bupropion	Step-1 antidepressant covered without authorization
citalopram	Step-1 antidepressant covered without authorization
Aripiprazole	Step-1 atypical antipsychotic covered without authorization
QVAR	Step-1 inhaled corticosteroid covered without authorization

Action required

Prior Authorization

Prior-authorization workflow updates — enforce 180-day lookback and Rebif two-fill rule

Update prior-authorization logic and workflows to enforce a 180-day prior-fill lookback for Step-2 agents and to require two prior Step-1 fills for Rebif products. These changes must be effective 2026-06-01.

Effective date and status

Effective Date2026-06-01

Policy StatusCURRENT

Drug groups with step rules4

Lookback period180 days

Rebif requirementRebif requires 2 prior Step-1 fills

Policy update changes

2026-06-01material_addedLatest

Tufts Medicare Preferred 2026 Step Therapy Medical Necessity Guidelines published with Step-1 and Step-2 designations for multiple drug groups; Step-2 agents (e.g., Emsam, Exxua, Fetzima, Asenapine, Fanapt, Fluticasone, Rebif) require evidence of prior fills within the previous 180 days (Rebif requires two or more prior Step-1 fills).