CurrentHealth NetPolicy CP.CPA.83

Step Therapy

Defines drugs requiring step therapy for Commercial lines (Centene/Health Net affiliated plans), the required step-through agents, maximum doses/quantity limits, approval durations, and continued therapy criteria. Applies to formulary drugs on Commercial formularies; non-formulary drugs follow separate exception policy.

Policy Summary

PayerHealth Net

PolicyStep Therapy

Policy CodePolicy CP.CPA.83

Change TypeMultiple step therapy additions, removals, and revisions (2023-2026)

Effective DateSep 1, 2018

Next Review Date

Key ActionProvider must submit documentation (office notes, labs, or other clinical information) supporting that the member has met all approval criteria.

SourceLink

POLICY UPDATE CHANGES

Added fluoxetine requiring step through two generic antidepressants (2Q 2026 annual review).

Removed Aplenzin, flurandrenolide ointment 0.05%, Azor, Tribenzor, Pataday Extra Strength, zileuton, Zyflo as step therapy not required (2Q 2026).

Revised Ubrelvy step-through agent requirements for California Commercial Exchange Plans from two to one 5HT1B/1D-agonist medication (March SDC updates).

Added Xhance requiring one formulary intranasal steroid; removed earlier limitation to California only (May/August 2023-2024 updates).

Added pregabalin immediate-release (Lyrica) requiring step through gabapentin and one of: antidepressant, anticonvulsant, buspirone, or cyclobenzaprine (Sept SDC 2025/2026).

Modified Applenzin required step through agents from two generic antidepressants to Bupropion XL; added clonidine XR with required step-through generic clonidine IR; added triamcinolone as example intranasal steroid (2Q 2025).

Removed several drugs from policy in previous reviews (e.g., Viibryd, Androderm, Atelvia) when not required or non-formulary.

~30+Drugs listed with step therapy requirements

12 months

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Typical approval duration

2026-05-26Most recent review date

Coverage Summary

This policy lists drugs requiring step therapy on Commercial formularies (Centene/Health Net affiliated plans). It defines required step-through agents, maximum doses/quantity limits, approval durations, and continued therapy criteria for coverage decisions. The policy stance is covered_with_criteria: drugs are covered when the member meets the specified prior trial or contraindication requirements and other criteria (documentation, dose/quantity limits).

Policy quick facts and thresholds

Approval duration12 months or duration of request, whichever is less

Typical approval duration12 months (typical)

Most recent review date2026-05-26

Approx. drugs with step therapy~30+

Initial Therapy — Step Therapy

Continued Therapy

Must meet ALL of the following for continued approval (approval duration 12 months or duration of request, whichever is less):

Continued Therapy criteria

Continuity of care or prior approval: Member meets one of the following: a) Currently receiving medication via Centene benefit or previously met initial approval criteria; OR b) Member is currently receiving medication and is enrolled in a state/product with continuity of care regulations (refer to state addendums CC.PHARM.03A and CC.PHARM.03B).
Dose increase constraint: If request is for dose increase, new dose does not exceed the FDA-approved maximum recommended dose and the quantity limit in initial approval criteria for the relevant drug.

Provider Actions & Prior Authorization

Prior Authorization

Documentation required for step therapy requests

Provider must submit documentation supporting that the member has met all approval criteria. Examples of acceptable documentation include office chart notes, lab results, or other clinical information.

Office chart notes
Laboratory results
Other relevant clinical information

Prior Authorization

Step-through trial or contraindication required

Approval requires evidence of a prior trial of the required step-through agent(s) or documentation of a contraindication to those agents.

Safety Notes / Prescribing Alerts

Safety clarification: Ubrelvy should not be prescribed concurrently with other CGRP inhibitors (examples: Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Vyepti).

Policy change note: Per March SDC updates, the required Ubrelvy step-through agents for California Exchange Plans were revised from two to one 5HT1B/1D-agonist medication (e.g., sumatriptan, rizatriptan, zolmitriptan).

Background

Background: This clinical policy enumerates medications that require prior step therapy trials on Commercial formularies and aligns with formulary management, clinical pharmacy messaging, and Pharmacy & Therapeutics (P&T) review. The policy is periodically updated by SDC and P&T to reflect formulary alignment, clinical guidance, and administrative changes.

Step-through agent definition: A formulary preferred or generic alternative medication that must be tried prior to approval of the requested drug.

Evidence & References

References: Clinical Pharmacology database and selected clinical guidelines (APA, ACP, AAN) cited. References were reviewed and updated through 2026.

Revision History

2Q 2026 (annual review) / 01.14.26 / P&T 05.26added (is_material)Latest

Added fluoxetine requiring step through two generic antidepressants (2Q 2026 annual review).

2Q 2026 (annual review) / 01.14.26 / P&T 05.26removed (is_material)

Removed Aplenzin, flurandrenolide ointment 0.05%, Azor, Tribenzor, Pataday Extra Strength, zileuton, Zyflo as step therapy not required (2Q 2026).

March SDC / 03.12.24

Policy Summary

PayerHealth Net

PolicyStep Therapy

Policy CodePolicy CP.CPA.83

Change TypeMultiple step therapy additions, removals, and revisions (2023-2026)

Effective DateSep 1, 2018

Next Review Date

Key ActionProvider must submit documentation (office notes, labs, or other clinical information) supporting that the member has met all approval criteria.

SourceLink

On This Page

Billing Rule

Dose and quantity limits enforced

Requests that exceed the stated maximum indicated dose or quantity limit for a drug will not meet criteria. Dose increases must not exceed the FDA‑approved maximum recommended dose and the stated quantity limit.

Tekturna HCT: maximum dose 300/25 mg/day
Taclonex (calcipotriene-betamethasone) ointment/suspension: maximum quantity 100 g/week (2 g/day)
Celecoxib (Oregon Commercial): maximum dose 800 mg/day (2 capsules)

Documentation Required

Continuity of care provision

For continued therapy, the provider must document that the member is currently receiving the medication via the Centene benefit or previously met initial approval criteria; alternatively, document that the member is currently receiving the medication and is enrolled in a state/product with continuity of care regulations per state addendums CC.PHARM.03A and CC.PHARM.03B.

Reference state addendums CC.PHARM.03A and CC.PHARM.03B for continuity of care rules

revised (is_material)

Revised Ubrelvy step-through agent requirements for California Commercial Exchange Plans from two to one 5HT1B/1D-agonist medication (March SDC updates).

May/August 2023-2024 / 05.04.23; 08.05.24added (is_material)

Added Xhance requiring one formulary intranasal steroid; removed earlier limitation to California only (May/August 2023-2024 updates).

Sept SDC 2025/2026 / 09.23.25 (SDC) / P&T 12.25added (is_material)

Added pregabalin immediate-release (Lyrica) requiring step through gabapentin and one of: antidepressant, anticonvulsant, buspirone, or cyclobenzaprine (Sept SDC 2025/2026).

2Q 2025 / 01.15.25 / P&T 05.25revised (is_material)

2022-2024 (multiple)removed (non-material)

Multiple administrative and formulary alignment changes across 2022-2024 (removed several drugs such as Viibryd, Androderm, Atelvia when not required or non-formulary).