Drugs That Require Step Therapy Prior to Coverage
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This policy lists specific drugs that require prior authorization and step therapy (trial of preferred generic or alternative agents) before HMSA Akamai Advantage (PPO) will provide coverage. It affects members enrolled in that plan and their prescribers seeking coverage for listed drugs.
No material clinical or coverage changes in this revision.
Drugs Requiring Step Therapy Prior to Coverage
Aripiprazole ODT
Coverage will be provided when the following is met:
From Step Therapy Group entry for ARIPIPRAZOLE ODT
Entecavir (BARACLUDE)
Coverage will be provided when the following is met:
From Step Therapy Group entry for BARACLUDE SOL / BARACLUDE
Lamotrigine ER
Coverage will be provided when the following is met:
From Step Therapy Group entry for LAMOTRIGINE
Levalbuterol Tartrate HFA
Coverage will be provided when the following is met:
From Step Therapy Group entry for LEVALBUTEROL
Olanzapine ODT
Coverage will be provided when the following is met:
From Step Therapy Group entry for OLANZAPINE ODT
Proton Pump Inhibitor - Esomeprazole Magnesium
Coverage will be provided when the following is met:
From Step Therapy Group entry for PPI / ESOMEPRAZOLE MAGNESIUM
Risperidone ODT
Coverage will be provided when the following is met:
From Step Therapy Group entry for RISPERIDONE ODT
Urinary Antispasmodics - Tolterodine Tartrate ER
Coverage will be provided when the following is met:
From Step Therapy Group entry for URINARY ANTISPASMODICS TOLTERODINE TARTRATE ER
Coding and Trial Duration
What Providers and Members Must Do
Prior Authorization Required
Prior Authorization is required for the drugs listed under the plan's step-therapy requirements. Coverage will only be provided after HMSA reviews and approves a prior authorization request in accordance with the criteria for each drug.
- Call HMSA at 1 (855) 479-3659 — available 24/7. TTY/TDD: 711.
- Customer service available in English and other languages.
Step Therapy Requirement Overview
Step therapy requires documented trials of specified generic alternatives (typically at least a 30‑day supply within the prior 180 days) before the preferred/brand drug will be approved. Examples include: aripiprazole ODT — try generic aripiprazole immediate‑release tablet; olanzapine ODT — try generic olanzapine immediate‑release tablet; select PPIs — try two of omeprazole, pantoprazole, or lansoprazole.
- Typical trial requirement: at least a 30‑day supply within the prior 180 days for the listed alternative.
- Some groups require trying one of several generics (e.g., urinary antispasmodics: oxybutynin, solifenacin, tolterodine, trospium).
How to Request Prior Authorization
To request prior authorization, the member, appointed representative, or prescriber must call HMSA at 1 (855) 479-3659. Provide clinical documentation supporting prior trials of required alternatives (dates, drug names, supply duration) and any rationale for medical necessity or exception.
- Document the alternative drug tried, dose, start/end dates, and confirmation of at least a 30‑day supply within the prior 180 days where required.
- Include clinical rationale if the member cannot tolerate or has contraindications to required alternatives.
Prior Authorization and Criteria Requirement
If prior authorization is not obtained or the step‑therapy criteria are not met (for example, no documented trial of the required generic alternative for the specified timeframe), the claim may be denied. Obtain and document required trials or submit clinical justification to avoid denial.
- Denial risk if no documented trial of required alternative (typically 30 days in prior 180 days).
- Provide clinical exception documentation when applicable to prevent claim denial.
Policy Background
Step therapy is a utilization management practice that requires a member to try one or more designated preferred or generic therapies before coverage is approved for a specified branded or non-preferred product. HMSA uses step therapy to confirm that a required prior trial of the alternative agent(s) has occurred — typically documented as a minimum supply — before authorizing the requested drug.
For the drugs listed in this policy, coverage is contingent on documentation that the member tried the specified alternative(s) as described in each drug’s step-therapy entry (for most entries this is a 30-day supply within the prior 180 days). Prior authorization must be requested and approved before the plan will provide coverage if the step therapy criteria are not met.
Definitions and Trial Requirements
Step Therapy Tables
| Drug | Required prior trial(s) |
|---|---|
| Aripiprazole ODT | |
| Generic aripiprazole immediate‑release tablet — documented trial of at least a 30‑day supply within the prior 180 days | |
| Entecavir (BARACLUDE) | |
| Generic entecavir tablets — documented trial of at least a 30‑day supply within the prior 180 days | |
| Lamotrigine ER | |
| Generic lamotrigine immediate‑release tablets or generic lamotrigine chewable/dispersible tablet — documented trial of at least a 30‑day supply within the prior 180 days | |
| Levalbuterol Tartrate HFA | |
| Albuterol HFA or Ventolin HFA — documented trial of at least a 30‑day supply within the prior 180 days | |
| Olanzapine ODT | |
| Generic olanzapine immediate‑release tablet — documented trial of at least a 30‑day supply within the prior 180 days | |
| Proton Pump Inhibitor - Esomeprazole Magnesium | |
| Two of the following generics: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules — each documented trial of at least a 30‑day supply within the prior 180 days | |
| Risperidone ODT | |
| Generic risperidone immediate‑release tablet — documented trial of at least a 30‑day supply within the prior 180 days |
| Drug | Required prior trial(s) |
|---|---|
| Tolterodine Tartrate ER (Urinary Antispasmodics) | |
| One of the following generics: oxybutynin tablets, oxybutynin solution, oxybutynin extended‑release tablets, solifenacin tablets, tolterodine immediate‑release tablets, or trospium immediate‑release tablets — documented trial of at least a 30‑day supply within the prior 180 days |
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