Drugs That Require Step Therapy (ST) Before Being Approved for Coverage
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Defines drugs that require step therapy (ST) before HMSA Akamai Advantage (PPO) will approve coverage and instructs how to request prior authorization; applies to members and prescribers under the HMSA Akamai Advantage plan.
No material clinical or coverage changes in this revision.
Step Therapy Coverage Criteria
Step therapy general criteria
Coverage is provided when the listed alternative(s) have been tried as specified for each drug/group
Examples in the chart: aripiprazole requires generic aripiprazole immediate; entecavir requires generic entecavir tablets; dorzolamide alternative for brinzolamide; lamotrigine requires immediate-release or chewable/dispersible generics; levalbuterol requires trial of albuterol HFA or Ventolin HFA; olanzapine ODT requires trial of generic olanzapine immediate; PPI group requires two 30-day trials of specified generics.
Risperidone ODT criteria
Specific example entries
Risperidone ODT requires prior trial of generic risperidone immediate‑release.
Initial step therapy trials
Typical initial trial requirements listed in the chart
Step Therapy Drug Table
| Step Therapy Group | Drug Name (listed) | Step Therapy Requirement |
|---|---|---|
| ARIPIPRAZOLE ODT | ||
| ARIPIPRAZOLE ODT | ||
| Coverage will be provided if at least a 30-day supply of generic aripiprazole immediate has been tried. | ||
| BARACLUDE (entecavir) | ||
| BARACLUDE | ||
| Coverage will be provided if at least a 30-day supply of generic entecavir tablets has been tried. | ||
| BRINZOLAMIDE | ||
| BRINZOLAMIDE | ||
| Coverage will be provided if at least a 30-day supply of dorzolamide 2% ophthalmic has been tried. | ||
| LAMOTRIGINE | ||
| LAMOTRIGINE ER / SUBVENITE | ||
| Coverage will be provided if at least a 30-day supply of generic lamotrigine immediate-release tablets or generic lamotrigine chewable/dispersible tablets has been tried. | ||
| LEVALBUTEROL | ||
| LEVALBUTEROL TARTRATE HFA | ||
| Coverage will be provided if at least a 30-day supply of albuterol HFA or Ventolin HFA has been tried. | ||
| OLANZAPINE ODT | ||
| OLANZAPINE ODT | ||
| Coverage will be provided if at least a 30-day supply of generic olanzapine immediate has been tried. | ||
| ESOMEPRAZOLE MAGNESIUM (PPI) | ||
| ESOMEPRAZOLE MAGNESIUM | ||
| Coverage will be provided if at least a 30-day supply of two of the following generic alternatives has been tried: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules. | ||
| RISPERIDONE ODT | ||
| RISPERIDONE ODT | ||
| Coverage will be provided if at least a 30-day supply of generic risperidone immediate-release tablet has been tried. |
Coding and Trial Supply
Prior Authorization and Provider Requirements
Prior Authorization Required
Prior authorization required for the drugs listed in the chart. HMSA will only approve coverage after it determines the prescription meets the step therapy criteria.
- Call HMSA at 1 (855) 479-3659 to request prior authorization (TTY/TDD 711).
- Requests may be made by the prescriber, the patient, or an appointed representative.
- Customer service is available 24/7 in English and other languages.
Step Therapy Requirement
Coverage is provided only after required trials of specified generic or preferred alternatives have been tried (commonly a 30-day supply). See the step therapy chart for the specific alternative(s) required for each drug.
- Typical requirement: at least a 30-day supply of the specified generic or preferred alternative(s).
- Examples from the chart: generic aripiprazole for aripiprazole ODT; generic entecavir for Baraclude; dorzolamide 2% ophthalmic for brinzolamide; generic lamotrigine immediate-release for lamotrigine ER; albuterol HFA or Ventolin HFA for levalbuterol tartrate HFA; generic olanzapine immediate-release for olanzapine ODT; two of omeprazole, pantoprazole, or lansoprazole for esomeprazole magnesium; generic risperidone immediate-release for risperidone ODT.
How to Request Prior Authorization
Prescribers, patients, or appointed representatives must request prior authorization by calling HMSA at 1 (855) 479-3659. TTY/TDD users should call 711. Requests are accepted 24 hours a day, 7 days a week.
Denial Risk if Step Therapy Criteria Not Met
Coverage will not be provided unless the drug is prescribed according to the step therapy criteria in the chart. Failure to meet the step therapy requirements may result in denial of coverage.
- Denial risk applies when required trials of specified alternatives (including the typical 30-day supply) have not been documented or completed.
- If step therapy criteria are not met, submit clinical justification with the prior authorization request for consideration.
Key Definitions
Policy Background
This policy implements step therapy by requiring that patients trial specified alternative medications before HMSA Akamai Advantage (PPO) will approve coverage for certain brand or specialty formulations. For the drugs listed in the chart, prior authorization is required and coverage will only be provided after HMSA determines the prescription meets the step therapy criteria described for each drug or group. Providers, patients, or appointed representatives must request prior authorization by calling HMSA at 1 (855) 479-3659 (TTY/TDD 711).
In most entries the requirement is a trial of the specified generic or preferred alternative for at least a 30-day supply (for example, trials of generic aripiprazole immediate-release before aripiprazole ODT, generic entecavir tablets before Baraclude, dorzolamide 2% ophthalmic before brinzolamide, or a 30-day trial of albuterol HFA/Ventolin HFA before levalbuterol HFA). For the proton pump inhibitor (PPI) group, coverage requires trials of two different 30-day supplies from the listed generics (omeprazole capsules, pantoprazole tablets, or lansoprazole capsules).
If the required step therapy trial(s) are not met, coverage will not be provided. Prescribers should follow the specific alternative and trial-duration requirements shown in the chart when requesting authorization.
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