Albuterol step therapy (levalbuterol and metformin solution listed under Albuterol policy header)
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Defines step therapy requirements for specific products (levalbuterol HFA and metformin 500 mg/5 ml oral solution) for new starts; applies to Health Alliance Plan members and prescribers submitting pharmacy claims.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Levalbuterol HFA (45 mcg/actuation) - Initial coverage
Covered when ALL of the following are met for levalbuterol HFA:
Step 2 product processes only after Step 1 claim
inv-02: Metformin 500 mg/5 ml oral solution - Initial coverage
Covered when ALL of the following are met for metformin 500 mg/5 ml oral solution:
Step 2 product processes only after Step 1 claim
Initial Therapy Requirements
inv-12: Initial therapy step requirement — New start processing requirement
For new starts only; the following must be met to process a Step 2 product:
Applicable examples: levalbuterol HFA requires prior albuterol HFA claim; metformin 500 mg/5 ml oral solution requires prior metformin tablet claim.
Step Therapy Rules
| Step | Product | Requirement |
|---|---|---|
| 2 | ||
| LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER | ||
| For new starts only: will process only if a claim for albuterol HFA was processed within the prior 120 days. |
| Step | Product | Requirement |
|---|---|---|
| 2 | ||
| metformin 500 mg/5 ml oral solution | ||
| For new starts only: will process only if a claim for metformin tablet was processed within the prior 120 days. |
Coding / Look-back Period
Provider Actions & Documentation
Step 2 prior use requirement
These products are designated Step 2 and have step therapy processing rules for new starts requiring prior use of the corresponding Step 1 product within 120 days.
- Step level: Step 2
- Look-back period: 120 days
- Applies to new starts only
Step therapy processing rule for new starts
For new starts only, coverage/processing of the Step 2 product requires evidence of a claim for the corresponding Step 1 product within the prior 120 days (albuterol HFA for levalbuterol HFA; metformin tablet for metformin 500 mg/5 ml oral solution).
- Requirement is limited to new starts
- Required look-back: 120 days
- Corresponding Step 1 product must have a processed claim
Levalbuterol: require prior albuterol HFA claim
Evidence of a processed claim for albuterol HFA within the prior 120 days is required for new starts of levalbuterol HFA.
- Look-back period: 120 days
- Applies only to new starts of levalbuterol HFA
Metformin solution: require prior metformin tablet claim
Evidence of a processed claim for metformin tablet within the prior 120 days is required for new starts of metformin 500 mg/5 ml oral solution.
- Look-back period: 120 days
- Applies only to new starts of metformin oral solution
Levalbuterol prior claim requirement and denial risk
Claims for levalbuterol HFA will be processed only if there is a claim for albuterol HFA in the past 120 days; absence of such a claim may result in denial or failure to process.
- Processing contingent on a processed albuterol HFA claim within 120 days
- No processing if prior claim not found for new starts
Metformin solution prior claim requirement and denial risk
Claims for metformin 500 mg/5 ml oral solution will be processed only if there is a claim for metformin tablet in the past 120 days; absence of such a claim may result in denial or failure to process.
- Processing contingent on a processed metformin tablet claim within 120 days
- No processing if prior claim not found for new starts
Background
This document lists the step therapy requirements for pharmacy products shown under the Albuterol policy heading. It applies to Health Alliance Plan members and prescribers submitting pharmacy claims and defines processing rules for new starts of the listed Step 2 products.
Specifically, the policy designates the listed products as Step 2 and requires evidence of prior use of the corresponding Step 1 product within a 120-day look-back period for new starts. For example, claims for LEVALBUTEROL HFA 45 MCG/ACTUATION will process only if a claim for albuterol HFA was processed in the past 120 days, and claims for metformin 500 mg/5 ml oral solution will process only if a claim for a metformin tablet was processed in the past 120 days.
Providers should confirm that a qualifying Step 1 claim exists within the 120-day prior-claim look-back when submitting requests for these Step 2 products to avoid denial or failure to process for new starts.
Definitions
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