2026 Medicare Part D Step Therapy Requirements
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Defines HealthPartners' Medicare Part D step therapy requirements effective May 1, 2026, specifying prior-use criteria for certain drugs on the Part D formulary. Affects Medicare Part D members and providers submitting pharmacy benefit claims under HealthPartners Part D.
No material clinical or coverage changes in this revision.
Coverage Criteria
RYTARY (carbidopa-levodopa ER) Initial Step Requirement
Covered when ALL of the following are met
Applies to the listed carbidopa-levodopa ER capsule strengths (23.75/95 mg, 36.25/145 mg, 48.75/195 mg, 61.25/245 mg).
Tazarotene topical Initial Step Requirement
Covered when ALL of the following are met
Applies to tazarotene 0.05% cream, 0.05% gel, and 0.1% gel listed as Step 2.
The policy text does not list any explicit clinical exclusions or contraindications for the Step 2 products. No conditions or patient clinical factors are specified in the document as reasons to exclude coverage beyond the stated prior-use requirements.
The document does not specify particular "not medically necessary" scenarios. Coverage determinations are governed by the Step Therapy rules: failure to meet the prior-use requirement described in the policy (see product-specific criteria) means the Step 2 product would not meet the stated coverage criteria.
Coding and Lookback
| CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG | CAPSULE, EXTENDED RELEASE |
| CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG | CAPSULE, EXTENDED RELEASE |
| CARBIDOPA ER 48.75 MG-LEVODOPA 195 MG | CAPSULE, EXTENDED RELEASE |
| CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG | CAPSULE, EXTENDED RELEASE |
| tazarotene 0.05% topical cream | product affected Step 2 |
| tazarotene 0.05% topical gel | product affected Step 2 |
| tazarotene 0.1% topical gel | product affected Step 2 |
Provider Actions and Documentation Requirements
Medicare Part D prior-use requirement for Step Therapy
For Medicare Part D claims, Step 2 coverage on HealthPartners’ Part D formulary (FID: 26132) requires documented prior use of the specified comparator product within the previous 12 months before the listed Step 2 products will be covered.
- Formulary identifier: FID: 26132
- Lookback period: within the previous 12 months
Step 2 requires prior use of specified comparator within 12 months
Coverage of the listed Step 2 products (RYTARY and tazarotene topical products) is contingent on prior use of the specified lower-step or comparator product within the previous 12 months; without this prior use the Step 2 product does not meet the step-therapy requirement.
- Applies to RYTARY (listed carbidopa‑levodopa ER capsule strengths) and the listed tazarotene topical products
- Required lookback: 12 months
Provide documentation of prior use within 12 months
Documented evidence must explicitly show prior use of the specified comparator (e.g., carbidopa‑levodopa immediate‑release or extended‑release tablets for RYTARY; tazarotene 0.1% cream for tazarotene Step 2 products) within the previous 12 months to satisfy the step‑therapy criterion.
- Evidence may include prior prescription fills or medical record notation demonstrating use within the previous 12 months
- Comparator examples: carbidopa‑levodopa immediate‑release or extended‑release tablets; tazarotene 0.1% cream
Lack of documented prior use may lead to denial
If there is no documentation showing prior use of the specified comparator product within the previous 12 months, coverage for the Step 2 product may be denied.
- Absence of prior‑use documentation is a basis for denial of coverage for the Step 2 products listed
Initial Therapy / Step 2 Prerequisites
Initial Therapy / Step 2 prerequisites
Prior documented use within the specified lookback period is required for coverage of Step 2 products listed below.
Step Therapy Table
| Requirement | Lookback period | Coverage implication |
|---|---|---|
| Prior documented use of the specified comparator product (e.g., carbidopa-levodopa immediate‑release or extended‑release tablets for RYTARY; tazarotene 0.1% cream for tazarotene topical products) is required before covering the Step 2 product. | ||
| 12 months (use within the previous 12 months) | ||
| Coverage granted only if documentation shows prior use within the 12‑month lookback; absence of prior use may result in denial of coverage for the Step 2 product. |
Definitions
Background
This policy lists Medicare Part D step therapy prior-use requirements for specific Part D formulary medications. For the products affected, coverage as a Step 2 product requires documented prior use of the specified comparator within a 12-month lookback period.
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