Step therapy and prior authorization requirements for select drugs (Antidepressants, Atypical Antipsychotics, Inhaled Corticosteroids, Interferons)
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Step therapy and prior authorization requirements for listed antidepressants, atypical antipsychotics, inhaled corticosteroids, and interferons for Tufts Health Plan Senior Care Options (HMO-SNP) members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Step Therapy Rules
Antidepressants
Antidepressants — coverage rules
Providers must supply paid pharmacy claim or physician documentation to demonstrate prior fills.
Atypical Antipsychotics
Atypical antipsychotics — coverage rules
Inhaled Corticosteroids
Inhaled corticosteroids — coverage rules
Interferons
Interferons — coverage rules
No additional exclusions are specified beyond the step therapy rules described for the listed drug classes. Coverage is determined by whether the member meets the Step-1 or Step-2 fill history requirements within the 180-day lookback period; if the required prior fills or documentation are not provided, Step-2 medications will be denied as described in the policy.
Providers must document prior therapy with either a paid pharmacy claim or physician documentation showing the member filled the required Step-1 (or Step-2 where allowed) medication(s) within 180 days; for interferons (Rebif and Rebif Rebidose) the policy requires documentation of two or more Step-1 fills in that period.
Step Therapy Placement by Drug Class
| Drug class | Step-1 (coverage) | Step-2 (coverage requirement) |
|---|---|---|
| Antidepressants | ||
| Bupropion, bupropion SR, bupropion XL, citalopram, desvenlafaxine ER, duloxetine delayed-release capsules, escitalopram, fluoxetine, fluoxetine delayed-release, fluvoxamine, paroxetine, sertraline, venlafaxine, venlafaxine ER — covered without prior authorization. | ||
| Emsam; Fetzima (including Fetzima Titration Pack); Exxua — Step-2. Covered only if 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. |
| Drug class | Step-1 (coverage) | Step-2 (coverage requirement) |
|---|---|---|
| Atypical antipsychotics | ||
| Aripiprazole, lurasidone, olanzapine, olanzapine‑fluoxetine, quetiapine, risperidone, ziprasidone — covered without authorization. | ||
| Asenapine; Fanapt (including Fanapt titration packs) — Step-2. Covered if 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. |
| Drug class | Step-1 (coverage) | Step-2 (coverage requirement) |
|---|---|---|
| Inhaled corticosteroids | ||
| QVAR — Step-1; covered without authorization. | ||
| Fluticasone products (e.g., Fluticasone Propionate HFA, Fluticasone Propionate Diskus) — Step-2. Covered if member has filled for one or more Step-1 inhaled corticosteroid medications within the previous 180 days as evidenced by a paid claim or physician documentation. |
| Drug class | Step-1 (coverage) | Step-2 (coverage requirement) |
|---|---|---|
| Interferons | ||
| Avonex, Betaseron, Plegridy — Step-1; covered without prior authorization. | ||
| Rebif; Rebif Rebidose (including Rebif/Rebidose titration packs) — Step-2. Covered only if member has filled for two or more Step-1 interferon medications within the previous 180 days as evidenced by a paid claim or physician documentation. |
Provider Requirements and Authorization Guidance
Antidepressant Step-2 prior fill required
Emsam, Fetzima, and Exxua (including titration packs) are Step-2; for coverage, providers must document that the member filled a Step-1 or Step-2 antidepressant within the prior 180 days.
- Required lookback period: 180 days
- Acceptable evidence: paid pharmacy claim or physician documentation
Atypical antipsychotic Step-2 prior fill required
Asenapine and Fanapt (and Fanapt titration packs) are Step-2; providers must show the member filled one or more Step-1 or Step-2 atypical antipsychotic medications within the previous 180 days for coverage.
- Required lookback period: 180 days
- Acceptable evidence: paid pharmacy claim or physician documentation
Inhaled corticosteroid Step-2 prior fill required
Fluticasone products are designated Step-2; providers must document that the member filled one or more Step-1 inhaled corticosteroid medications within the prior 180 days to obtain coverage.
- Required lookback period: 180 days
- Acceptable evidence: paid pharmacy claim or physician documentation
Interferon (Rebif) Step-2 two-fill requirement
Rebif and Rebif Rebidose are Step-2 and require documentation that the member filled two or more Step-1 interferon medications within the previous 180 days for coverage.
- Required number of Step-1 fills: ≥ 2 within 180 days
- Acceptable evidence: paid pharmacy claim or physician documentation
General step therapy requirement
Step therapy applies across the listed classes: Step-1 agents are covered without prior authorization; Step-2 agents require prior fill history (one or two fills as specified) within the prior 180 days to be covered.
- Step-1: covered without authorization
- Step-2: requires evidence of prior fills within 180 days
Evidence required to verify prior fills
Providers must supply evidence of required prior medication fills by submitting paid pharmacy claims or physician documentation showing the member filled the Step-1 (or Step-2 when allowed) medication(s) within the previous 180 days; for Rebif, documentation must show two or more Step-1 fills.
- Acceptable documentation: paid pharmacy claim or physician documentation
- Lookback period: 180 days (two fills required for Rebif)
Denial risk if required prior fills are not provided
If there is no evidence of the required number of filled Step-1 (or Step-2 where specified) medications within the previous 180 days, coverage for the Step-2 medication will be denied.
- Denial applies to listed Step-2 agents (examples: Emsam, Fetzima, Exxua; Asenapine, Fanapt; Fluticasone; Rebif) when prior-fill evidence is absent
Coding and Lookback Parameters
Background
This document defines step therapy placement and prior authorization requirements for selected medications in four drug classes: antidepressants, atypical antipsychotics, inhaled corticosteroids, and interferons for Tufts Health Plan Senior Care Options (HMO‑SNP) members. It specifies which agents are designated Step-1 (covered without prior authorization) and which are Step-2 (require evidence of prior fills).
The policy uses a 180-day lookback for prior medication fills to satisfy Step-2 requirements. For most Step-2 agents a single prior fill of a Step-1 (or Step-2 where permitted) within 180 days is required; for Rebif and Rebif Rebidose the policy requires documentation of two or more Step-1 interferon fills within the previous 180 days.
Definitions
Revision History
Step therapy and prior authorization requirements (180-day lookback; class-specific prior-fill counts) take effect for Tufts Health Plan Senior Care Options (HMO-SNP).
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