2026 Step Therapy Criteria
Customize your policy alerts
Sign up for all Health Net policy alerts
Know when Health Net releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Health Net's 2026 step therapy requirements for covered antidepressants, antipsychotics (oral), dextromethorphan/bupropion, and trazodone products; applies to prior authorization and coverage determinations for members under this payer.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Antidepressant Initial/Step therapy — Antidepressants — Covered when the following are met
Antidepressants — Covered when the following are met
Exceptions: Approve Exxua without prerequisite trial for suicidal ideation, or if patient is currently/previously taking Exxua.
inv-02: Oral antipsychotics Initial/Step therapy — Oral antipsychotics — Covered when the following are met
Oral antipsychotics — Covered when the following are met
Approve if the member is currently taking Fanapt or has taken Fanapt in the past.
inv-03: Dextromethorphan/bupropion Initial/Step therapy — Dextromethorphan/bupropion — Covered when the following are met
Dextromethorphan/bupropion — Covered when the following are met
Approve Auvelity without prerequisite trials if suicidal ideation is present, or if patient is currently/previously taking Auvelity.
inv-04: Trazodone Initial/Step therapy — Trazodone — Covered when the following are met
Trazodone — Covered when the following are met
Document trial of trazodone 100 mg or 150 mg (tablet); tablet strengths listed also include 50 mg.
inv-05: Initial coverage criteria for Raldesy — Covered when ONE of the following is met:
Covered when ONE of the following is met:
Step 1 tablet strengths listed: 50 mg, 100 mg, 150 mg
Exception to prior tablet trial requirement
Allows continuation without tablet trial
The policy does not list separate clinical exclusions beyond the stated step therapy rules and the enumerated exceptions. Coverage limitations are governed by the step requirements for each drug group and the documented exceptions for current/prior use or suicidal ideation; no additional disorder-specific or diagnosis-based exclusions are specified in these sections.
None explicitly stated in this section.
Initial Therapy Criteria
inv-32: Antidepressant initial therapy — Antidepressant Step 1 products
Antidepressant Step 1 products
Includes listed bupropion formulations, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine.
inv-33: Antipsychotic initial therapy — Oral antipsychotic Step 1 products
Oral antipsychotic Step 1 products
A trial of the brand name equivalent of a generic Step 1 product counts toward the requirement.
inv-34: Dextromethorphan/bupropion initial therapy — Dextromethorphan/bupropion Step 1 products
Dextromethorphan/bupropion Step 1 products
Step 1 includes listed generic SSRIs/SNRIs and bupropion formulations.
inv-35: Initial therapy for Raldesy — Initial coverage requires trial of generic trazodone tablet formulation unless exception applies
Initial coverage requires trial of generic trazodone tablet formulation unless exception applies.
Tablet strengths listed in policy: 50 mg, 100 mg, 150 mg
Raldesy is listed as Step 2
Continuation Therapy Criteria
inv-36: Continuation therapy — Continuation allowed without prior tablet trial when patient is currently taking or has previously taken Raldesy
Continuation allowed without prior tablet trial when patient is currently taking or has previously taken Raldesy.
No prior tablet trial required for ongoing users.
Step Therapy Summary
| Requirement | Details |
|---|---|
| One Step 1 trial required | |
| Coverage for Step 2 antidepressant products is provided if ONE Step 1 drug has been tried (defined as at least a 1-day supply in the prior 180 days). Exceptions: approve Exxua without prerequisite trial for suicidal ideation or if patient is currently/previously taking Exxua. |
| Requirement | Details |
|---|---|
| Two Step 1 trials required | |
| Coverage for Fanapt (Step 2 oral antipsychotic) requires that TWO different Step 1 oral antipsychotic drugs have been tried (each at least a 1-day supply in the prior 180 days). Approve if the member is currently taking Fanapt or has taken Fanapt in the past. |
| Requirement | Details |
|---|---|
| SSRI/SNRI plus bupropion required | |
| Coverage for Auvelity requires prior trials of a generic SSRI or SNRI AND bupropion (each at least a 1-day supply in the prior 180 days). Exception: approve Auvelity without prerequisite trials if the patient has suicidal ideation, or if the patient is currently/previously taking Auvelity. |
| Requirement | Details |
|---|---|
| Trazodone Step 1 trial required | |
| Coverage for Raldesy (Step 2 oral solution) implies prior trial of Step 1 trazodone products (e.g., trazodone 100 mg or 150 mg tablets) before Step 2 coverage is approved. |
| Step | Required agent or condition |
|---|---|
| Step 1 | |
| Trial of a generic trazodone tablet (50 mg, 100 mg, or 150 mg) — defined as at least a 1-day supply in the prior 180 days. | |
| Step 2 | |
| Raldesy oral solution (10 mg/mL) — may be approved if Step 1 trial documented, or if an exception applies (difficulty swallowing tablets, or patient is currently/previously taking Raldesy). |
Provider Actions & Documentation Requirements
Antidepressants — Step 1 trial required
Step 2 antidepressant coverage requires documentation that the patient tried at least one Step 1 antidepressant (defined as at least a 1-day supply within the prior 180 days) unless the Exxua exception applies for suicidal ideation or current/prior Exxua use.
- Trial definition: at least a 1-day supply in the prior 180 days.
- Exception: Approve Exxua without prerequisite trial if patient has suicidal ideation, or if currently/previously taking Exxua.
Antipsychotics — two Step 1 trials required
Coverage for Step 2 oral antipsychotics (e.g., Fanapt) requires prior trials of two different Step 1 oral antipsychotics (each defined as at least a 1-day supply in the prior 180 days) unless the member is currently taking Fanapt or has taken it in the past.
- Each Step 1 trial must be at least a 1-day supply within the prior 180 days.
- A trial of the brand-name equivalent of a generic Step 1 product counts.
- Approve if currently or previously taking Fanapt.
Auvelity — prerequisite trials required
Auvelity (dextromethorphan/bupropion) requires prior trials of a generic SSRI or SNRI AND bupropion (each at least a 1-day supply in the prior 180 days) before Step 2 coverage, unless the patient has suicidal ideation or is currently/previously taking Auvelity.
- Required: one generic SSRI or SNRI trial PLUS a bupropion trial (each ≥1-day supply in prior 180 days).
- Exception: approve without prerequisite trials for suicidal ideation or current/prior Auvelity use.
Prior authorization for Raldesy
Prior authorization for Raldesy requires evidence of a trial of an approved Step 1 trazodone tablet (at least a 1-day supply in the prior 180 days) per the step sequence, or documentation of an allowed exception such as difficulty swallowing tablets or current/prior use of Raldesy.
- Step 1 requirement: tablet dosage form of generic trazodone (50 mg, 100 mg, or 150 mg) tried within prior 180 days.
- Exceptions: swallowing impairment or current/prior Raldesy use allow approval without tablet trial.
Antidepressants step therapy
Step 2 antidepressant products are covered only after a documented trial of one Step 1 antidepressant (at least a 1-day supply in the prior 180 days) unless an exception (suicidal ideation or current/prior Exxua use) applies.
- Step 1 drugs include listed generics (Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Venlafaxine).
- Trial look-back: at least a 1-day supply within prior 180 days.
Oral antipsychotics step therapy
Coverage for Fanapt (Step 2 oral antipsychotic) requires documented trials of two different Step 1 oral antipsychotics (each at least a 1-day supply in the prior 180 days) unless the member is currently or previously taking Fanapt.
- Step 1 agents are the listed oral antipsychotics in the policy (chunks 8–9).
- Each Step 1 trial must meet the 1-day supply in prior 180 days definition.
Dextromethorphan/bupropion step therapy
Coverage for Auvelity (Step 2 dextromethorphan/bupropion) requires prior trials of a generic SSRI or SNRI plus bupropion (each at least a 1-day supply in the prior 180 days), unless the patient has suicidal ideation or is currently/previously taking Auvelity.
- Step 1 agents are the listed generic SSRIs/SNRIs and bupropion products (chunk 13).
- Each required trial must be at least a 1-day supply within the prior 180 days.
Trazodone step therapy
Trazodone step therapy requires a trial of listed Step 1 trazodone tablets (100 mg or 150 mg; 50 mg also listed in details) before approval of Raldesy oral solution (Step 2), unless an exception applies.
- Step 1: trazodone 100 mg or 150 mg tablets (50 mg tablet also noted in details).
- Step 2: Raldesy 10 mg/mL oral solution — approve if Step 1 trial documented or exception applied.
Step therapy sequence
The policy enforces a two-step sequence for trazodone → Raldesy: Step 1 is trial of generic trazodone tablets (50 mg, 100 mg, or 150 mg; at least a 1-day supply in the prior 180 days); Step 2 is Raldesy oral solution (10 mg/mL) if Step 1 criteria are met or an allowed exception is documented.
- Document tablet trial: at least a 1-day supply within the prior 180 days.
- Allowed exceptions: difficulty swallowing tablets or current/prior Raldesy use.
Antidepressant documentation
For antidepressant Step 2 requests, include documentation showing a trial of at least one Step 1 antidepressant (at least a 1-day supply in the prior 180 days) or documentation that an exception applies (suicidal ideation or current/prior Exxua use).
- Record dates, agent name, and quantity to confirm at least a 1-day supply in the prior 180 days.
- If relying on an exception, document suicidal ideation or evidence of current/prior Exxua use.
Antipsychotic documentation
For Step 2 oral antipsychotic requests, provide documentation of trials of two different Step 1 oral antipsychotics (each at least a 1-day supply in the prior 180 days) or documentation that the member is currently/previously taking Fanapt.
- Document agent names, dates, and supply to meet the 1-day supply/180-day look-back.
- If approving based on current/prior Fanapt use, include evidence of prior Fanapt therapy.
Dextromethorphan/bupropion documentation
For Auvelity requests, document prior trials of a generic SSRI or SNRI AND bupropion (each at least a 1-day supply in the prior 180 days), or documentation of suicidal ideation or current/prior Auvelity use to justify an exception.
- Provide agent names, dates, and dispensed days' supply to confirm each trial met the 1-day supply/180-day requirement.
- If exception claimed, document suicidal ideation or evidence of current/prior Auvelity.
Required documentation
Document a prior medication trial of a generic trazodone tablet (at least a 1-day supply within the prior 180 days) to support Raldesy initial coverage, or document inability to swallow tablets or current/prior Raldesy use to support an exception.
- Tablet strengths listed: 50 mg, 100 mg, 150 mg — record dates and days' supply.
- If patient cannot swallow tablets, include clinical documentation of swallowing impairment.
Antidepressants Step 1 requirement
Coverage will be denied for Step 2 antidepressant requests if the prerequisite Step 1 drug has not been tried (defined as at least a 1-day supply in the prior 180 days) and no allowable exception is documented.
- Ensure one Step 1 trial is documented or provide exception evidence (suicidal ideation or current/prior Exxua use) to avoid denial.
Antipsychotics Step 1 requirement
Coverage for Fanapt (Step 2 antipsychotic) will be denied unless documentation shows two Step 1 oral antipsychotic trials (each at least a 1-day supply in the prior 180 days) or evidence the member is currently/previously taking Fanapt.
- Each Step 1 trial must meet the 1-day supply/180-day definition to avoid denial.
- If member has current/prior Fanapt use, include supporting evidence.
Dextromethorphan/bupropion Step requirements
Coverage for Auvelity (Step 2) will be denied unless the record documents trials of a generic SSRI or SNRI plus bupropion (each at least a 1-day supply in the prior 180 days), unless an exception (suicidal ideation or current/prior Auvelity use) is documented.
- Confirm dates and days' supply for both the SSRI/SNRI and bupropion trials to meet the requirement.
- If claiming an exception, include documentation of suicidal ideation or prior/current Auvelity therapy.
Prior tablet trial requirement
Coverage for Raldesy is contingent on prior use of a tablet dosage form of generic trazodone (at least a 1-day supply within the prior 180 days) unless the patient has difficulty swallowing tablets or is currently/previously taking Raldesy.
- If no prior tablet trial is documented, include clinical evidence of swallowing impairment or evidence of current/prior Raldesy use to avoid denial.
- Tablet trial must meet the 1-day supply/180-day look-back.
Coding & Look-back Definitions
Definitions & Product Notes
Background
This document defines Health Net’s step therapy (prior therapy) requirements used to manage utilization of selected psychotropic drug groups: antidepressants, oral antipsychotics, dextromethorphan/bupropion combination products, and trazodone. For covered Step 2 agents the policy generally requires documented prior trials of listed Step 1 agents defined as at least a 1-day supply in the prior 180 days. Specific exceptions allow approval without prerequisite trials for certain brand products when the member has suicidal ideation or is currently/previously taking the product (for example, Exxua and Auvelity), and a swallowing-impairment or ongoing-use exception applies to Raldesy.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.