Step Therapy Criteria — Levalbuterol HFA and Metformin Oral Solution
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Defines step therapy prerequisites for coverage of levalbuterol HFA 45 mcg/actuation inhaler and metformin 500 mg/5 ml oral solution for HAP members; affects new starts and pharmacy claims processing.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial step therapy requirements
Covered when ALL of the following are met for new starts:
applies to new starts only
Initial Therapy Criteria
Levalbuterol initial therapy
Levalbuterol HFA initial coverage condition for new starts
new starts only
Metformin solution initial therapy
Metformin oral solution initial coverage condition for new starts
new starts only
Step Therapy Details
| Step | Product | Requirement |
|---|---|---|
| 2 | LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER | For new starts only: a processed claim for albuterol HFA within the prior 120 days is required. |
| Step | Product | Requirement |
|---|---|---|
| 2 | metformin 500 mg/5 ml oral solution | For new starts only: a processed claim for metformin tablet within the prior 120 days is required. |
Coding / Lookback
Provider Actions and Billing Rules
Levalbuterol prior-claim processing
No separate prior authorization is defined; processing for new-start levalbuterol HFA claims is contingent on a processed albuterol HFA claim within the prior 120 days.
Metformin prior-claim processing
No separate prior authorization is defined; processing for new-start metformin 500 mg/5 ml oral solution claims is contingent on a processed metformin tablet claim within the prior 120 days.
Levalbuterol step requirement
For new starts, coverage of LEVALBUTEROL HFA 45 mcg/actuation requires evidence of a processed albuterol HFA claim within the prior 120 days.
- Applies to new starts only
- Lookback period: 120 days
Metformin solution step requirement
For new starts, coverage of metformin 500 mg/5 ml oral solution requires evidence of a processed metformin tablet claim within the prior 120 days.
- Applies to new starts only
- Lookback period: 120 days
Levalbuterol documentation
For new starts, providers must document or have pharmacy claims showing a processed albuterol HFA claim in the 120 days prior to a levalbuterol HFA claim to allow processing.
- Documentation or pharmacy claim must show prior albuterol HFA processed within 120 days
Metformin documentation
For new starts, providers must document or have pharmacy claims showing a processed metformin tablet claim in the 120 days prior to a metformin solution claim to allow processing.
- Documentation or pharmacy claim must show prior metformin tablet processed within 120 days
Levalbuterol prior-claim requirement
Claims for levalbuterol HFA submitted for new starts will only process if there is a processed claim for albuterol HFA within the previous 120 days; absence of that prior claim may result in denial.
- Lookback requirement: 120 days
- Requirement applies to new starts only
Metformin solution prior-claim requirement
Claims for metformin 500 mg/5 ml oral solution submitted for new starts will only process if there is a processed claim for metformin tablet within the previous 120 days; absence of that prior claim may result in denial.
- Lookback requirement: 120 days
- Requirement applies to new starts only
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