ModifiedHealth NetPolicy CP CPA.83

Step therapy requirement list for commercial formulary drugs

Defines drugs that require step therapy and the conditions under which Health Net commercial members may receive coverage; affects providers submitting prior authorization for formulary drugs on commercial lines of business in NC and other applicable states listed in the policy.

Policy Summary

PayerHealth Net

PolicyStep therapy requirement list for commercial formulary drugs

Policy CodePolicy CP CPA.83

Change TypeMaterial updates — multiple drugs added/removedapproval duration revised

Effective DateSep 1, 2018

Next Review Date

Key ActionProviders must document prior trials of required step-through agents or contraindications and submit supporting clinical documentation with the prior authorization request.

SourceLink

POLICY UPDATE CHANGES

Added multiple drugs to the step therapy list including Lastacaft, olopatadine 0.7% ophthalmic solution, Oxtellar XR, desoximetasone spray, Ubrelvy, Xhance, and celecoxib with specified step requirements.

Revised approval duration for Commercial line of business to 12 months or duration of request, whichever is less.

Removed several products from the step therapy list including Tudorza Pressair, Seebri Neohaler, Symtuza, Viibryd, Androderm, fluoxetine, Envarsus XR, desvenlafaxine, Tekturna, and Cimduo.

Ubrelvy step requirement revised to require step through one SHT IB/D-agonist medication for California Commercial Exchange Plans.

Xhance added to policy with requirement of one intranasal steroid; later clarification about state applicability removed.

Applenzin step requirement modified from two generic antidepressants to require step through Bupropion XL.

Clonidine extended release (Nexiclon XR) added with required step through generic clonidine immediate release.

Atelvia removed from policy as it is non-formulary.

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Coverage Criteria Overview

Initial Therapy

Covered when ALL of the following are met

Initial Approval: 1) Requested drug is listed in the step therapy table; 2) Provider documents prior trial(s) of the required step-through agent(s) listed for that drug or documents contraindication/intolerance to required agents; 3) Requested dose does not exceed the maximum indicated dose and stated quantity limit; 4) Approval duration limited to 12 months or duration of request, whichever is less.

See therapy table for drug-specific required agents and quantity limits.

Continued Therapy

Continuation of therapy allowed when ANY of the following are met

Continued Therapy: a) Member is currently receiving medication via Centene/Health Net benefit or previously met initial approval criteria; b) Member is currently receiving medication and is enrolled in a state/product with continuity of care regulations.

Providers must document prior approval or continuity status in the request.

Dose increase condition: If request is for a dose increase, the new dose does not exceed the FDA‑approved maximum recommended dose and the quantity limit as stated in the initial approval criteria.

Approval duration: 12 months or duration of request; whichever is less.

Example drug-specific step therapy criteria (partial—document continues elsewhere)

Policy contains multiple 'covered with criteria' step therapy rules that require prior trials of specific agents before authorizing certain drugs; state-specific variations are included.

Ubrelvy requires prior trial(s) of SHT IB/D‑agonist medications (examples: sumatriptan, rizatriptan, zolmitriptan). Number of required agents varies by plan: California Exchange Plans require one SHT IB/D‑agonist; other commercial formularies require two prior SHT agents.1 or 2 agents depending on plan

Clarified in 03/12/2024 and 07/16/2024; Ubrelvy should not be prescribed concurrently with CGRP inhibitors.

Xhance: Coverage requires prior trial of one formulary intranasal steroid (examples: fluticasone propionate, mometasone, budesonide, triamcinolone).1 intranasal steroid trial

Initial CA‑only clarification later removed; applies per current formulary guidance.

Applenzin: As of 2Q2025, Applenzin requires prior trial of Bupropion XL (generic Wellbutrin XL or Forfivo XL) rather than two generic antidepressants.

This step therapy policy applies only to drugs that are on the Commercial formulary. Drugs that are non-formulary are not governed by this step therapy policy; for coverage questions or to request coverage of a non-formulary drug, refer to the formulary exceptions process (see policy CP CPA.190).

Per the 2Q 2024 annual review, Atelvia was removed from this policy because it is non-formulary. Providers should follow formulary exception procedures (CP CPA.190) for any requests related to Atelvia.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for drugs subject to this policy. Approvals are generally issued for up to 12 months or for the duration of the request, whichever is less. Continuation/renewal requests should document that the member continues to meet the continuation criteria; dose increases must not exceed the FDA‑approved maximum and the quantity limits stated in the initial approval criteria.

Approval duration: 12 months or duration of request; whichever is less.
Approvals may be limited to the duration of the requested therapy.

Documentation Required

Documentation Required with Request

The provider must submit supporting clinical documentation with the prior authorization request. Acceptable documentation includes office chart notes, results of relevant laboratory tests, prior prescription records, and any other clinical information that verifies trials of required step-through agents, contraindications, intolerance, or clinical rationale for bypassing step therapy.

Initial Therapy — Drug-specific Step Requirements

Initial Therapy — examples of drug-specific required step-through agents, maximum doses, and quantity limits

Drug-specific required step-through agents, maximum doses, and quantity limits (examples)

Aplenzin (bupropion hydrobromide SR): Required step-through agents: Bupropion XL (generic Wellbutrin XL or generic Forfivo XL). Maximum dose: 348 mg/day (1 tablet/day).

Astagraf XL (tacrolimus SR): Required step-through agents: Generic tacrolimus. Maximum dose: 0.2 mg/kg/day.

Aptiom (eslicarbazepine): Required step-through agents: Carbamazepine or oxcarbazepine. Maximum dose: 1,600 mg/day.

Bepreve (bepotastine): Required step-through agents: Generic ophthalmic olopatadine and either azelastine or epinastine. Maximum dose (quantity limit): 2 drops/eye/day (0.34 mL/day).

Continuation Therapy

Continuation Therapy — criteria for members already on therapy

Continued therapy criteria: Member currently receiving medication via Centene/Health Net benefit or previously met initial approval criteria; or member is under applicable continuity of care rules.

Dose and duration condition: If request is for a dose increase, new dose does not exceed FDA‑approved maximum recommended dose and the quantity limit stated in the initial approval criteria. Approval duration for continued therapy: 12 months or duration of request; whichever is less.

Step Therapy Table and Requirements

Drug	Required prior step agent(s) / condition	Maximum dose or quantity limit
Aplenzin (bupropion hydrobromide SR)	Prior trial of Bupropion XL (generic Wellbutrin XL or generic Forfivo XL)	348 mg/day (1 tablet/day)
Astagraf XL (tacrolimus SR)	Prior trial of generic tacrolimus	0.2 mg/kg/day
Aptiom (eslicarbazepine)	Prior trial of carbamazepine or oxcarbazepine	1,600 mg/day
Bepreve (bepotastine)	Prior trial of generic ophthalmic olopatadine and either azelastine or epinastine	2 drops/eye/day (0.34 mL/day)
Calcipotriene-betamethasone (Taclonex)	Prior trial of a generic topical steroid and either topical calcitriol or calcipotriene (topical formulations)	100 g/week (2 g/day)
Clonidine extended release (Nexiclon XR)	Prior trial of generic clonidine hydrochloride immediate release	0.5?2 mg/day (documented in source as 0.52 mg/day maximum)
Lastacaft (alcaftadine ophthalmic solution 0.25%) / Pataday Extra Strength (olopatadine 0.7%)	Prior trial of Patanol or Pataday AND azelastine or epinastine (for Lastacaft); generic ophthalmic olopatadine and either azelastine or epinastine (for Pataday/Lastacaft)	1 bottle/month
Modafinil (Provigil)	Prior trial of armodafinil (Nuvigil)	200 mg/day (shift work disorder); 400 mg/day (other indications)
Oxtellar XR (oxcarbazepine)	Prior trial of generic Trileptal (oxcarbazepine)	2,400 mg/day
Retin-A Micro (tretinoin microsphere gel)	Prior trial of a generic tretinoin product	Once daily application
Trintellix (vortioxetine)	Prior trial of two generic antidepressants (note: quantity limit removed in 2Q2025)	20 mg/day (quantity limit removed per 2Q2025 update)
Ubrelvy (ubrogepant)	Prior trial of SHT IB/D-agonist migraine medication(s): For California Exchange Plans — one SHT (e.g., sumatriptan, rizatriptan, zolmitriptan); For California & Oregon Commercial formularies — two SHT migraine medications	Varies (see policy)
Xhance (fluticasone propionate)	Prior trial of one formulary intranasal steroid (e.g., fluticasone propionate, mometasone, budesonide, triamcinolone)	Varies (see policy)
Zileuton ER / Zyflo (zileuton)	Prior trial of generic montelukast	2,400 mg/day

Provider documentation required	Examples of acceptable documentation / notes
Documentation of prior medication trials or contraindications	Office chart notes, medication history, pharmacy fill records, or progress notes documenting trial and response or intolerance to required step agent(s)
Specifics for Ubrelvy	Documentation showing prior trial(s) of specified SHT IB/D-agonist(s) (e.g., sumatriptan, rizatriptan, zolmitriptan); note plan-specific requirement (1 agent for CA Exchange Plans; 2 agents for other CA & OR commercial formularies)
Specifics for Xhance	Documentation showing prior trial of one formulary intranasal steroid (examples: fluticasone propionate, mometasone, budesonide, triamcinolone) or documentation of contraindication/intolerance
Specifics for Applenzin and other antidepressants	Documentation of prior trial of Bupropion XL (generic Wellbutrin XL/Forfivo XL) for Applenzin per 2Q2025 update, or documentation of prior two generic antidepressants when applicable for other agents (historical criteria)
General required supporting materials	Office chart notes, lab results, pharmacy fill history, prior authorization forms that indicate dates/duration of trial, reason for discontinuation (e.g., adverse effect), and confirmation of formulary status where applicable

Quantity Limits and Specific Drug Limits

inv-23: Bepreve — quantity limit 2 drops/eye/day (0.34 mL/day)

DrugBepreve (bepotastine)

Quantity limit2 drops/eye/day (0.34 mL/day)

Required step-through agentsGeneric ophthalmic olopatadine, and either azelastine or epinastine

inv-24: Pataday/Lastacaft ophthalmic solutions — quantity limit 1 bottle/month

DrugsPataday Extra Strength (olopatadine 0.7%) and Lastacaft (alcaftadine 0.25%)

Quantity limit1 bottle/month

Required step-through agents

Abbreviations and Definitions

inv-15: ARB definition

TermARB = angiotensin receptor blocker

Use in policyUsed to define required step-through agents for certain combination products (e.g., olmesartan-containing products)

ReferenceSee Appendix A: Abbreviation/Acronym in policy

inv-16: Abbreviations (ER, IR, SR, NSAID, HCTZ, etc.)

ER/IR/SR/XLER = extended-release; IR = immediate-release; SR = sustained-release; XL = extended-release

NSAIDNSAID = non-steroidal anti-inflammatory drug

HCTZ

Policy Background

Step therapy is a utilization management strategy that requires a member to try one or more specified preferred or generic agents (the “step-through” agents) before coverage will be provided for a higher-cost or non-preferred medication. The purpose is to ensure that members receive clinically appropriate, lower-cost alternatives first while allowing coverage of the requested agent when the required trials are documented or when a listed agent is contraindicated or not tolerated.

Under this policy, drug-specific step therapy rules identify the required prior agents, any applicable maximum doses or quantity limits, and plan- or state-specific variations; documentation of prior trials or clinical justification must be submitted with authorization requests. Approval for drugs covered under step therapy is typically granted for up to 12 months or the duration of the request, whichever is less, and continuation of therapy may be allowed when members have previously met initial approval criteria or are covered under applicable continuity-of-care rules.

Revision History and Material Changes

2020-10-07removal

Removed Tudorza Pressair and Seebri Neohaler from the step therapy list per SDC and clinical guidance.

2020-11-16removal

Removed Atripla from the policy per SDC and prior clinical guidance.

2021-02-24addition

Added Lastacaft (requiring step through Patanol or Pataday and either azelastine or epinastine), olopatadine 0.7% ophthalmic solution, Oxtellar XR, and desoximetasone spray with specified step requirements during the 2Q 2021 annual review.

Policy Summary

PayerHealth Net

PolicyStep therapy requirement list for commercial formulary drugs

Policy CodePolicy CP CPA.83

Change TypeMaterial updates — multiple drugs added/removedapproval duration revised

Effective DateSep 1, 2018

Next Review Date

Key ActionProviders must document prior trials of required step-through agents or contraindications and submit supporting clinical documentation with the prior authorization request.

SourceLink

On This Page

Denial Risk

Denial Risk for Missing Step-Therapy Documentation

Failure to provide adequate documentation of required step therapy trials (for example, records showing trials of required generic or formulary-preferred agents, dates of therapy, and reason for discontinuation) may result in denial of the request. If the member has a documented contraindication or intolerance to required step-through agents, include clinical evidence to support this.

Denial risk if trials of step-through agents are not documented or dates are missing.
If member had adverse reaction or intolerance, submit clinical notes describing the reaction and relevant lab/test results.

Step Therapy

Step-Therapy Requirements and Examples

This policy contains mandated step-through (step therapy) requirements for many branded and specialty products. Prior to approval, providers must document trials of the specific required agents listed in the step-therapy table (or provide justification such as contraindication/intolerance). Examples include: Ubrelvy (ubrogepant) — step-through requirements vary by product and market (see policy history and clarifications below); Xhance (fluticasone propionate) — requires trial of one formulary intranasal steroid (examples: fluticasone propionate, mometasone, budesonide, triamcinolone); and many other agents in the step table requiring specific generic or formulary alternatives.

Providers must follow the specific required step-through agents noted for each drug in the policy table.
Where the policy or state/product addendum specifies different requirements (e.g., California Exchange Plans vs other commercial formularies), follow the applicable plan/product clarification.

Initial step requirements (examples)

Initial step requirements (examples) — updated step requirements for specific agents

Ubrelvy initial step: Prior trial of specified SHT IB/D‑agonist agents (examples: sumatriptan, rizatriptan, zolmitriptan) is required; number of required agents depends on plan (California Exchange Plans = 1; other commercial formularies = 2).1 or 2 agents depending on plan

See plan‑specific guidance in the policy.

Applenzin initial step (2Q2025 update): Requirement changed from two generic antidepressants to prior trial of Bupropion XL (generic Wellbutrin XL/Forfivo XL).Prior trial of Bupropion XL

Modified during 2Q2025 annual review.

Clonidine XR (Nexiclon XR) initial step (2Q2025 addition): Requires prior trial of generic clonidine hydrochloride immediate‑release before approving extended‑release clonidine.Prior trial of immediate‑release clonidine

Added in 2Q2025.