DraftHawaii Medical Service Association (HMSA)Policy N/A

Step therapy and prior authorization requirements for selected drugs (coverage criteria)

Defines step therapy groupings and criteria for coverage of aripiprazole ODT (and placeholders for many other groups); affects providers submitting prior authorization or coverage requests to HMSA.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyStep therapy and prior authorization requirements for selected drugs (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide documentation of at least a 30-day supply of the specified generic alternative when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

425+indexed entries

1explicit groups

30-daymin trial

72chunks

Coverage Criteria

Step Therapy Group 1 (ARIPIPRAZOLE ODT)

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Coverage for Step Therapy Group 1 (ARIPIPRAZOLE ODT) when specific criterion met

Step Therapy Group 1 requirement: Coverage will be provided if at least a 30-day supply of generic aripiprazole immediate>=30 days supply

Only this criterion text is present in the provided excerpt

BARACLUDE - Initial step requirement

Coverage condition listed for BARACLUDE

Baraclude step therapy: Coverage will be provided if at least a 30-day supply of generic entecavir tablets has been tried.30-day supply

applies to BARACLUDE (entecavir)

BRINZOLAMIDE - Initial Step Therapy

Covered when the following is met for BRINZOLAMIDE

BRINZOLAMIDE step therapy: At least a 30-day supply trial of dorzolamide 2% ophthalmic solution has been tried>=30 days

coverage provided if tried

Initial step requirement — lamotrigine ER

Covered when the following prior trial is met for lamotrigine ER:

Lamotrigine ER prior trial: At least a 30-day supply of generic lamotrigine immediate-release tablets or generic lamotrigine chewable/dispersible tablet has been tried.>=30 days

From Step Therapy Criteria, 1

Step Therapy - Levalbuterol

Covered when the following is met

Step therapy for levalbuterol: Member has used at least a 30-day supply of albuterol HFA or Ventolin HFA30-day supply

Levalbuterol (levalbuterol tartrate HFA) coverage contingent on this trial

Initial Step: Short-acting beta-agonist trial

Covered when the following step therapy condition is met (fragment):

Albuterol trial: At least a 30-day supply of albuterol HFA or Ventolin HFA has been tried30-day supply

Present in fragment

Drug listing

Drug listed in step therapy groups (fragment):

OLANZAPINE ODT listing: OLANZAPINE ODT is listed under step therapy criteria

No further criteria provided in fragment

Olanzapine ODT - Initial step requirement

Covered when ALL of the following are met for olanzapine ODT:

Olanzapine ODT step requirement: Member has tried at least a 30-day supply of generic olanzapine immediate-release tablet30 days

From Step Therapy Criteria entry #1

Initial therapy

Covered when ALL of the following are met

Step therapy trials: At least a 30-day supply of two of the following generic alternatives (omeprazole capsules, pantoprazole tablets, lansoprazole capsules) have been tried.30-day; 2 agents

Initial coverage criteria

Covered when ALL of the following are met:

Prior trial requirement: Member has used at least a 30-day supply of generic risperidone immediate-release.>= 30 days

Document supply or dispensing record.

Step Therapy — risperidone (explicit)

Covered when the following step therapy requirement is met:

Risperidone step: At least a 30-day supply trial of generic risperidone immediate-release tablet has been tried.30-day supply

Appears as a step therapy criterion associated with one or more step therapy groups in this fragment.

Initial Step Therapy

Covered when ALL of the following are met

Step therapy prerequisite: At least a 30-day supply of generic risperidone immediate-release tablet has been tried.30-day supply

Evidence of trial required

Step Therapy Criterion (excerpt)

Covered when the following step therapy criterion is met (excerpt):

Criterion 1: At least a 30-day supply of generic risperidone immediate-release tablet has been tried.30-day supply

Appears as Step Therapy Criterion 1 in this document extract.

The provided excerpt contains a long enumeration of step therapy criteria placeholders but no explicit exclusion list. Where criteria entries are blank, no exclusions are stated in this portion of the document.

Within the Drug Names / Step Therapy Group listing shown here, multiple entries are empty and no exclusions are specified for the listed drugs. The index format lists drug name slots but does not itself define any exclusionary conditions.

Across the expanded criteria index many entries are blank; this fragment does not provide additional exclusion language. No specific exclusions are identified in the populated olanzapine ODT criterion fragment or the surrounding placeholder entries.

The document portion supplied is primarily a numbered step therapy index with many empty criteria slots; it does not include affirmative exclusion statements elsewhere in these chunks. Any exclusionary policy statements would need to be referenced from other sections not present in this extract.

No broad 'not medically necessary' declarations appear in the excerpt. However, the olanzapine ODT step therapy entry explicitly conditions coverage on a prior trial: if the required trial of a 30-day supply of generic olanzapine immediate‑release tablet is not documented, coverage for olanzapine ODT would not meet the stated criterion and therefore may be considered not covered under this step therapy requirement.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization / Step Therapy Overview

Prior authorization and step-therapy requirements are in force for multiple oral and ophthalmic agents listed below. Providers should verify that required prior trials of the specified generic alternatives (typically a 30-day supply) are documented before submitting a request. Requests that do not show the required step therapy trial(s) may be denied.

Step therapy index: multiple Step Therapy Groups exist; where a specific drug is listed in a group the policy requires prior trial of the group's listed generic alternative(s) before coverage of the brand/formulation.
Possible denial: requests that do not meet the step therapy requirement (no documentation of required prior trial) may be denied.
No explicit denial triggers beyond failure to meet step therapy are provided in this excerpt; some entries show placeholders only.

Step Therapy

BRINZOLAMIDE — Prior Authorization / Step Therapy

BRINZOLAMIDE (ophthalmic) requires prior step therapy. Coverage will be provided if at least a 30-day supply of dorzolamide 2% ophthalmic solution has been tried. Include documentation of the trial of the generic dorzolamide (dates, amount dispensed or prescribed).

Drug: BRINZOLAMIDE (ophthalmic)
Step requirement: 30-day supply trial of dorzolamide 2% ophthalmic solution
Documentation required: evidence of prior trial (prescription fill history, medical record note)

Step Therapy

Olanzapine ODT — Step Therapy

OLANZAPINE ODT is subject to step therapy: coverage will be provided if at least a 30-day supply of generic olanzapine immediate‑release tablets has been tried. Requests should include documentation of that generic trial. Absent that documentation, the request may be denied.

Drug: OLANZAPINE ODT
Step requirement: 30-day supply trial of generic olanzapine immediate‑release tablets
Documentation required: prescription/fill history or clinical note showing trial

Step Therapy

Risperidone ODT — Step Therapy / Prior Authorization

RISPERIDONE ODT is subject to step therapy. Coverage will be provided if at least a 30‑day supply of generic risperidone immediate‑release tablets has been tried. Providers must document the prior trial (dates and fill information). The policy references a generic risperidone trial as the usual prerequisite; failure to show this trial is a common denial trigger.

Drug: RISPERIDONE ODT
Step requirement: 30-day supply trial of generic risperidone immediate‑release
Documentation required: proof of prior trial (prescription or pharmacy claim)
Denial trigger: no documentation of required generic risperidone trial

Note

Step Therapy Index & Example Criteria (partial)

Step therapy index entries (partial) indicate multiple Step Therapy Groups and Drug Names; where a group maps to a drug the accompanying Step Therapy Criteria state the generic alternatives that must be tried. Examples in this excerpt include ARIPIPRAZOLE ODT, BARACLUDE (entecavir requirement), LAMOTRIGINE ER, LEVALBUTEROL, ESOMEPRAZOLE MAGNESIUM, and others. Many entries in the source are placeholders or incomplete — providers should consult the live prior authorization portal or payor formulary for the authoritative rule set.

Index example: ARIPIPRAZOLE ODT appears in the Step Therapy Group index and has a criterion requiring trial of generic aripiprazole immediate formulation (30-day supply).
BARACLUDE (entecavir): Coverage will be provided if at least a 30‑day supply of generic entecavir tablets has been tried.
LAMOTRIGINE ER: Coverage requires trial of a 30‑day supply of generic lamotrigine immediate‑release tablets or generic chewable/dispersible formulations.
LEVALBUTEROL TARTRATE HFA: Coverage requires trial of a 30‑day supply of albuterol HFA or Ventolin HFA.
ESOMEPRAZOLE MAGNESIUM: Coverage requires trial of a 30‑day supply of two of the following generics: omeprazole, pantoprazole, or lansoprazole.

Documentation Required

Documentation Requirements (consolidated)

Documentation: for any prior authorization or step therapy exception request include specific proof of prior trials (drug name, dosage, dates, dispensing pharmacy or claims record) or clinical rationale for why the member cannot use the step agents (allergy, intolerance, contraindication, or clinical failure). Where the excerpt specifies a required generic trial (e.g., risperidone, olanzapine, aripiprazole, lamotrigine, entecavir, dorzolamide), include the 30‑day supply trial evidence.

Required documentation (general): prescription fill history, pharmacy claims, clinician progress note documenting intolerance or contraindication, or prior authorization denial from another insurer where applicable.
If requesting an exception, provide clinical justification and supporting records.

Prior Authorization

Provider Actions to Support Authorization

Provider action checklist (consolidated): verify the applicable Step Therapy Group for the requested drug; confirm required generic alternative(s) and that a 30‑day supply was tried; attach pharmacy claim or prescription fill history; if the member cannot tolerate or has contraindication to the step agent, include clinical notes explaining why. If the policy text shows only placeholders or no explicit denial triggers, treat the absence of a documented trial as the operative denial risk.

Check step therapy index to identify required prior agent(s).
Document 30‑day generic trial or clinical rationale for exception.
Submit all supporting records with the PA request to avoid processing delays or denial.

Note

Incomplete Entries / Placeholders — Operational Note

Notes about incomplete entries and placeholders: parts of the source extract contain numerous empty placeholders (Step Therapy Criteria numbered entries with no text). Where no explicit denial triggers or documentation requirements are shown in this excerpt, assume the general rules above apply and consult the payer’s online PA tool for the finalized criteria.

No explicit denial triggers beyond failure to meet step therapy are provided in this extract.
Several Step Therapy placeholders are present; confirm live policy for full rules.

Initial Therapy Criteria

inv-85: Initial therapy requirement (aripiprazole ODT group)

At least a 30-day supply of generic aripiprazole immediate is required as the initial step for coverage of aripiprazole ODT.

Initial step: At least a 30-day supply of generic aripiprazole immediate must be provided>=30 days supply

Quantity/dispensing documentation should be provided to demonstrate trial.

inv-86: BARACLUDE initial therapy requirement

Initial step therapy requirement for BARACLUDE

Trial of generic entecavir: At least a 30-day supply of generic entecavir tablets must have been tried before Baraclude will be provided.30-day supply

explicit in chunk 32

inv-87: BRINZOLAMIDE initial therapy requirement

Step therapy requirement for BRINZOLAMIDE

Prior topical carbonic anhydrase inhibitor trial: At least a 30-day supply of dorzolamide 2% ophthalmic solution has been tried>=30 days

required prior to BRINZOLAMIDE coverage

inv-88: Lamotrigine ER initial therapy

Initial therapy requirement for lamotrigine ER:

Prior trial: Trial of at least a 30-day supply of generic lamotrigine immediate-release or chewable/dispersible tablet.>=30 days

Step Therapy Criteria, 1

inv-89: Initial Therapy

Initial coverage condition

Initial therapy requirement: At least a 30-day supply of albuterol HFA or Ventolin HFA must have been provided/used prior to levalbuterol coverage30-day supply

inv-90: Initial therapy requirement (partial)

Initial therapy requirement present in fragment

Short-acting beta-agonist trial: Coverage will be provided if at least a 30-day supply of albuterol HFA or Ventolin HFA has been tried30-day supply

Exact phrasing from chunk 112

inv-91: Olanzapine ODT initial therapy requirement

Initial coverage condition for olanzapine ODT

Trial of generic immediate-release olanzapine: At least a 30-day trial of generic olanzapine immediate-release tablets must have been attempted before coverage of olanzapine ODT30 days

Entry #1

inv-92: Step therapy for esomeprazole magnesium

Required trials before coverage: Coverage will be provided if at least a 30-day supply of two of the following generic alternatives have been tried: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.30-day; 2 agents

inv-93: Initial therapy requirement

Prior trial requirement for initiating risperidone ODT

Generic risperidone trial: At least a 30-day supply of generic risperidone immediate-release must have been provided prior to coverage of risperidone ODT.>= 30 days

inv-94: Initial therapy requirement

Step therapy prerequisite for coverage

Required prior trial: Trial of at least a 30-day supply of generic risperidone immediate-release tablet.30-day supply

Documented trial required

Step Therapy Index & Rules

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	ARIPIPRAZOLE ODT	Generic aripiprazole immediate — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	BARACLUDE (entecavir)	Generic entecavir tablets — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	BRINZOLAMIDE	Dorzolamide 2% ophthalmic solution — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
—	(index placeholder)	No specific prior-agent or trial described in this excerpt	No coverage rule provided in fragment

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	LAMOTRIGINE ER	Generic lamotrigine immediate‑release or chewable/dispersible — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	LEVALBUTEROL (levalbuterol tartrate HFA)	Albuterol HFA or Ventolin HFA — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	(enumerated placeholders) — example: LEVALBUTEROL	Where specified, prior-agent trial of at least a 30-day supply is required (examples include albuterol HFA / Ventolin HFA)	Covered when respective prior trials documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	OLANZAPINE ODT	Generic olanzapine immediate‑release tablet — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	ESOMEPRAZOLE MAGNESIUM	Two of: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules — each for at least a 30-day supply	Covered when two generic PPI trials documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	RISPERIDONE ODT	Generic risperidone immediate‑release tablet — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	RISPERIDONE (step requirement repeated)	Generic risperidone immediate‑release tablet — trial of at least a 30-day supply required	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	RISPERIDONE (duplicate listing)	Generic risperidone immediate‑release tablet — at least a 30-day supply	Covered when prior trial documented

Step	Drug / Group	Required prior agent(s) / trial	Coverage
1	RISPERIDONE ODT (additional duplicate)	Generic risperidone immediate‑release tablet — at least a 30-day supply	Covered when prior trial documented

Index #	Drug name (placeholder)	Notes / required prior trial
1	Many numbered placeholders (entries through at least 425)	Most entries contain no criteria; populated examples require ≥30-day trials of specified generics (see individual rows)

Definitions & Named Drugs

LAMOTRIGINE (index entry)

TermLAMOTRIGINE

Index listingListed as a step therapy drug name in the document's Drug Names/Step Therapy index

Clinical detail availableNo clinical definition or indication provided in this excerpt

LAMOTRIGINE ER (index entry)

TermLAMOTRIGINE ER

Index listingListed as a step therapy drug name (extended‑release) in the document's index

Required prior trial (context)Step Therapy Criteria example shows ER formulations referenced with prior trial requirements elsewhere in the document

Olanzapine ODT (definition-like entry)

TermOlanzapine ODT

Step therapy requirementCoverage will be provided if at least a 30-day supply of generic olanzapine immediate has been tried

Index contextAppears as Step Therapy Criteria, 1 = OLANZAPINE ODT in the Step Therapy Criteria listing

RISPERIDONE ODT (index entry)

TermRISPERIDONE ODT

Index listingListed in the document's Drug Names list as 'RISPERIDONE ODT'

Associated step therapy contextDocument includes step therapy criteria elsewhere that require a 30-day trial of generic risperidone immediate-release prior to coverage of ODT formulations

RISPERIDONE ODT (duplicate index entry)

TermRISPERIDONE ODT

Repeated index entriesRISPERIDONE ODT is explicitly repeated across multiple Drug Names listings in the extract

Coverage implicationStep therapy sections indicate prior trial of generic risperidone immediate-release (30 days) is required for related coverage requests

Quantity Limits

generic aripiprazole immediate — minimum supply

Druggeneric aripiprazole immediate

Minimum supply>= 30-day supply (required as the step therapy trial before coverage of aripiprazole ODT)

Document sourceExplicitly stated in Step Therapy Criteria, 1: 'Coverage will be provided if at least a 30-day supply of generic aripiprazole immediate.'

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyStep therapy and prior authorization requirements for selected drugs (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide documentation of at least a 30-day supply of the specified generic alternative when requesting coverage or prior authorization.

SourceLink

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