CurrentHawaii Medical Service Association (HMSA)Policy N/A

Drugs That Require Step Therapy Prior to Coverage

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.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyDrugs That Require Step Therapy Prior to Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization by calling HMSA at 1 (855) 479-3659 and document required prior trials (e.g., pharmacy claims showing a 30-day supply within the prior 180 days).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug entries with step therapy requirements

30 daysminimum trial duration

180lookback period (days)

Drugs Requiring Step Therapy Prior to Coverage

Aripiprazole ODT

Coverage will be provided when the following is met:

Aripiprazole ODT step therapy: Generic aripiprazole immediate release tablet has been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for ARIPIPRAZOLE ODT

Entecavir (BARACLUDE)

Coverage will be provided when the following is met:

Entecavir step therapy: Generic entecavir tablets have been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for BARACLUDE SOL / BARACLUDE

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyDrugs That Require Step Therapy Prior to Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization by calling HMSA at 1 (855) 479-3659 and document required prior trials (e.g., pharmacy claims showing a 30-day supply within the prior 180 days).

SourceLink

On This Page

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Lamotrigine ER

Coverage will be provided when the following is met:

Lamotrigine ER step therapy: Generic lamotrigine immediate release tablets or generic lamotrigine chewable/dispersible tablet have been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for LAMOTRIGINE

Levalbuterol Tartrate HFA

Coverage will be provided when the following is met:

Levalbuterol step therapy: Albuterol HFA or Ventolin HFA have been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for LEVALBUTEROL

Olanzapine ODT

Coverage will be provided when the following is met:

Olanzapine ODT step therapy: Generic olanzapine immediate release tablet has been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for OLANZAPINE ODT

Proton Pump Inhibitor - Esomeprazole Magnesium

Coverage will be provided when the following is met:

PPI alternatives step therapy: Two of the following generic alternatives have been tried for at least a 30-day supply within the prior 180 days: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.two agents, each 30-day supply within prior 180 days

From Step Therapy Group entry for PPI / ESOMEPRAZOLE MAGNESIUM

Risperidone ODT

Coverage will be provided when the following is met:

Risperidone ODT step therapy: Generic risperidone immediate release tablet has been tried for at least a 30-day supply within the prior 180 days.30-day supply within prior 180 days

From Step Therapy Group entry for RISPERIDONE ODT

Urinary Antispasmodics - Tolterodine Tartrate ER

Coverage will be provided when the following is met:

Urinary antispasmodic alternatives: One of the following generics has been tried for at least a 30-day supply within the prior 180 days: oxybutynin tablets, oxybutynin solution, oxybutynin extended-release tablets, solifenacin tablets, tolterodine immediate-release tablets, or trospium immediate-release tablets.30-day supply within prior 180 days

From Step Therapy Group entry for URINARY ANTISPASMODICS TOLTERODINE TARTRATE ER

Coding and Trial Duration

inv-09: Prior trial duration — at least a 30-day supply within the prior 180 days

RequirementAt least a 30-day supply of the alternative agent within the prior 180 days

Lookback period180 days (prior to the date of request)

Minimum trial duration30 days (minimum supply to document trial)

Documentation acceptedPharmacy claims or prescriptions demonstrating the 30-day supply within the prior 180 days

What Providers and Members Must Do

Prior Authorization

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

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).

Documentation Required

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.

Denial Risk

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

inv-15: Step Therapy Trial — definition: documented trial of specified alternatives for at least a 30-day supply within prior 180 days

DefinitionA documented trial of one or more specified generic or alternative medications for at least a 30-day supply within the prior 180 days

Required evidencePharmacy claims or prescriptions showing a minimum 30-day supply of the listed alternative(s) within the prior 180 days

Number of agents (when specified)Follow drug-specific rules (e.g., PPIs require two specified generics each tried for at least a 30-day supply)

ApplicabilityApplies to each listed product requiring step therapy before the brand/non-preferred product will be approved

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