Step-therapy implies prior authorization

Prior authorization is required when step therapy applies: the provider must confirm and document the specified prior trial(s) for the requested medication before approval is granted.

• Prior authorization will verify required prior therapies were tried and failed, as detailed in each medication's criteria.

Confirm required prior trials on PA

For medications listed as subject to step therapy, prior authorization requests must include evidence that the required prior trials outlined in the criteria have been completed.

• Providers should supply documentation of prior agents, dates, and outcomes per the criteria for each product.

BEVESPI: trial of Anoro AND Stiolto required

BEVESPI AEROSPHERE will only be approved if the patient has tried BOTH Anoro and Stiolto prior to the request.

• Document trials of Anoro and Stiolto (agent names and dates) on the prior authorization submission.

Pimecrolimus: tacrolimus + topical steroid required

Pimecrolimus is subject to step therapy and requires documented prior trials of tacrolimus AND at least one topical corticosteroid listed in the criteria before approval.

• Required corticosteroids include betamethasone, clobetasol, hydrocortisone, or triamcinolone — document agent(s), dates, and outcomes.

Dificid requires prior oral vancomycin trial

Dificid (fidaxomicin) requires a prior trial of oral vancomycin; prior authorization must document that oral vancomycin was tried.

• Include evidence of oral vancomycin therapy (agent, dates, and response) with the PA request.

Edarbyclor: prior ARB/combination trial required

Edarbyclor is subject to step therapy and requires a prior trial of at least one of the listed ARBs or ARB combinations before coverage.

• Document which ARB or ARB combination was used and the trial dates on the PA submission.

Envarsus XR requires generic tacrolimus trial

Envarsus XR (tacrolimus ER) requires a prior trial of generic tacrolimus; prior authorization must include documentation of that trial.

• Provide evidence of generic tacrolimus use (agent name, dates, and reason for failure/intolerance) with the PA.

Equetro: prior generic carbamazepine trial required

Equetro requires documentation of a prior trial on at least one generic carbamazepine formulation (ER or IR) before approval.

• Include agent name (generic carbamazepine ER or IR), dates of therapy, and outcome in the PA documentation.

Femring requires prior estradiol cream trial

Femring is subject to step therapy and will require documentation of a prior trial of estradiol cream for coverage.

• Document estradiol cream use (agent, dates, and response) with the prior authorization request.

Umeclidinium Ellipta requires Spiriva trial

Umeclidinium Ellipta requires a prior trial of Spiriva; PA requests must document prior Spiriva therapy.

• Include Spiriva treatment details (agent, dates, and outcome) in the prior authorization submission.

Clindamycin‑BPO 1.2%–5% required before NEUAC products

Topical clindamycin–benzoyl peroxide formulations (1.2%–5%) are required first-line prior therapies for listed NEUAC topical agents; documented prior use of clindamycin‑BPO 1.2%–5% is required.

• Provide product used, concentration, dates, and outcome when submitting PA for NEUAC agents.

SEGLUROMET/STEGLATRO require two SGLT2 trials

SEGLUROMET and STEGLATRO require documented prior trials on TWO of the listed SGLT2 inhibitors (dapagliflozin, Farxiga, Jardiance) before approval.

• Chart evidence must show trials of two listed SGLT2 agents (agent names and dates).

Carbidopa‑levodopa ER products subject to step therapy

Multiple extended‑release carbidopa‑levodopa products are subject to step therapy; refer to criteria for required prior therapies.

• Prior authorization must follow the specific ER carbidopa‑levodopa criteria listed in the policy.

Pramipexole ER requires pramipexole IR trial

Pramipexole ER requires a documented prior trial of pramipexole immediate‑release before approval.

• Document pramipexole IR use (agent, dates, and outcome) on the PA.

Prucalopride requires prior Linzess trial

Prucalopride succinate requires a prior trial of Linzess; PA requests must include documentation of Linzess therapy.

• Provide evidence of Linzess use (agent, dates, and response) in the prior authorization.

Prucalopride succinate: Linzess documentation required

Prucalopride succinate is specifically listed as subject to step therapy and will be denied without documentation of a Linzess trial.

• Absence of Linzess documentation may result in non‑authorization.

Qelbree requires atomoxetine + guanfacine/clonidine

Qelbree requires prior trials of atomoxetine AND one of guanfacine or clonidine; PA must document both prior agents.

• Include agent names, dates, and outcomes for atomoxetine and guanfacine or clonidine with the PA.

Rasuvo requires prior generic methotrexate trial

Rasuvo requires a prior trial of generic methotrexate; documentation of that trial is required for approval.

• Provide dates and response to generic methotrexate on the PA submission.

Soolantra requires prior azelaic acid or topical metronidazole

Ivermectin 1% cream (Soolantra) requires a prior trial of at least one of azelaic acid or topical metronidazole; include documentation of such trial in the PA.

• Document which topical (azelaic acid or metronidazole), dates, and outcome.

Pitavastatin requires prior trial on listed generic statin

Pitavastatin calcium requires a prior trial on at least one listed generic statin (e.g., atorvastatin, rosuvastatin); PA must document that prior trial.

• Specify which statin was tried, dates, and reason for failure/intolerance.

Stimulants: trial of listed alternative stimulant required

Listed stimulant formulations (specific lisdexamfetamine strengths and methylphenidate) are subject to step therapy and require documented prior trial on one of the listed alternative stimulants; note that step therapy is not required for lisdexamfetamine when used for binge‑eating disorder.

• Document prior trial on amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, or methylphenidate caps/tabs, unless for binge‑eating disorder.

Sunosi requires prior generic wakefulness agent trial

Sunosi requires a prior trial of at least one generic wakefulness agent (for example modafinil or armodafinil); prior authorization must document such a trial.

• Provide agent name(s), dates, and treatment response for prior wakefulness agent(s).

PA must document specified prior trials before approval

Prior authorization for any medication subject to step therapy will require evidence that the specified prior trials in that medication's criteria have been completed (trial agent(s), dates, and outcome).

• Providers must document failure, intolerance, or contraindication to required prior agents when applicable.

Ophthalmic agents require prior prostaglandin analog trial

For listed ophthalmic agents (Rhopressa, Rocklatan, Vyzulta), coverage requires a prior trial of latanoprost, bimatoprost, or Lumigan; include documentation of that prior therapy with the PA.

• Document which prostaglandin analog was used, dates, and response.

Vaginal estrogens require prior generic vaginal estradiol trial

For listed vaginal estrogen products (IMVEXXY starter/maintenance, Premarin cream), a prior trial of generic vaginal estradiol is required and must be documented with the PA.

• Include evidence of generic vaginal estradiol use (agent, dates, and outcome).

Step-therapy medications: member must try and fail prior therapies

Medications listed as subject to step therapy will only be covered when the member has tried and failed the specified prior therapies detailed in each medication's criteria; providers must supply documentation to satisfy the step requirements.

• Follow the exact prior‑trial lists in each criteria section and include agent names, dates, and treatment outcomes.

BEVESPI denial risk if Anoro and Stiolto not tried

BEVESPI AEROSPHERE specifically requires trials of both Anoro and Stiolto; absence of documentation for both may result in denial.

• Failure to document trials of Anoro AND Stiolto may lead to non‑authorization.

Budesonide ER denial risk without mesalamine trial

Budesonide ER requires a prior trial of mesalamine; lack of documentation of mesalamine use may result in denial.

• Document mesalamine therapy (agent, dates, and response) with the PA.

Caduet denial risk without prior statin and amlodipine trials

Caduet (amlodipine‑atorvastatin) requires prior trials on at least one listed statin AND amlodipine; absence of both prior trials may trigger denial.

• PA should include which statin was used and documentation of prior amlodipine therapy.

Clomipramine denial risk without prior TCA trial

Clomipramine formulations require documentation of a prior trial on at least one listed tricyclic antidepressant; missing documentation may lead to denial.

• Provide agent name(s), dates, and outcome for the required tricyclic trial.

Corlanor denial risk without prior beta‑blocker (exception noted)

Corlanor (ivabradine) requires a prior trial on at least one listed beta‑blocker except in pediatric dilated cardiomyopathy; document prior beta‑blocker therapy or applicable exception.

• If pediatric dilated cardiomyopathy applies, indicate the exception; otherwise document beta‑blocker trial details.

Dapsone 5% gel denial risk without required topicals

Dapsone 5% gel requires prior use of topical clindamycin AND topical erythromycin; lack of documentation may result in denial.

• Include both topical agents, dates, and outcomes in the PA documentation.

Pimecrolimus denial risk without tacrolimus + steroid trials

Pimecrolimus coverage may be denied if the patient has not trialed tacrolimus and at least one of the listed topical corticosteroids; provide documentation of those prior trials.

• Required steroids listed: betamethasone, clobetasol, hydrocortisone, triamcinolone — include agent and dates.

Dificid denial risk without oral vancomycin trial

Dificid (fidaxomicin) may be denied if oral vancomycin was not tried first; ensure oral vancomycin trial documentation is provided.

• Provide oral vancomycin treatment details (dates, response) with the PA.

Envarsus denial risk without generic tacrolimus trial

Envarsus XR may be denied if a generic tacrolimus trial is not documented; include evidence of generic tacrolimus use when requesting Envarsus.

• Document agent, dates, and reason for switch or failure.

Umeclidinium denial risk without Spiriva trial

Umeclidinium Ellipta may be denied if a prior trial of Spiriva is not documented; include Spiriva therapy details with the PA.

• Failure to document Spiriva use may trigger non‑authorization.

Clindamycin‑BPO documentation required or denial risk

Failure to document prior use of clindamycin‑BPO 1.2%–5% may trigger denial for NEUAC topical agents; include product, concentration, dates, and outcome.

• Documentation must show use of clindamycin‑BPO within the 1.2%–5% concentration range.

SGLT2 agents: two prior trials required or denial risk

For SEGLUROMET/STEGLATRO, absence of documented trials on two of dapagliflozin, Farxiga, and Jardiance may result in non‑authorization; include chart evidence of two trials.

• Specify the two SGLT2 agents tried and dates in the PA submission.

Olopatadine denial risk without azelastine trial

Not documenting a prior trial of azelastine nasal spray may lead to denial for olopatadine HCl 0.6% solution; include azelastine trial details.

• Provide agent, dates, and response to azelastine nasal spray.

Pramipexole ER denial risk without IR trial

No documented prior trial of pramipexole IR may trigger denial for pramipexole ER; include pramipexole IR treatment details in the PA.

• Document agent, dates, and outcome for pramipexole IR.

Prucalopride denial risk without Linzess trial

Failure to document a Linzess trial may result in denial for prucalopride; include Linzess therapy evidence on the PA.

• Provide Linzess dates and treatment response.

Qelbree denial risk without required prior agents

Absence of documented atomoxetine plus guanfacine or clonidine trials may trigger denial for Qelbree; PA must show both prior agents were tried.

• Include atomoxetine and either guanfacine or clonidine treatment details (dates and outcomes).

Rasuvo denial risk without methotrexate trial

No prior trial of generic methotrexate may trigger denial for Rasuvo; document methotrexate therapy details with the PA request.

• Provide generic methotrexate dates and response information.

Soolantra denial risk without prior topical trial

No prior trial of azelaic acid or topical metronidazole may trigger denial for Soolantra (ivermectin 1% cream); include documentation of prior topical trial.

• State which topical was used, dates, and treatment outcome.

Pitavastatin denial risk without prior generic statin

No prior trial on at least one listed generic statin may trigger denial for pitavastatin calcium; include prior statin trial documentation.

• List the statin tried, dates, and reason for failure/intolerance.

Stimulant denial risk without prior alternative stimulant trial

For lisdexamfetamine and methylphenidate patches, lack of prior trial on one of the listed alternative stimulants may trigger denial; note that step therapy is not required for binge‑eating disorder.

• Document prior alternative stimulant agent, dates, and response; indicate if binge‑eating disorder exception applies.

Sunosi denial risk without prior wakefulness agent trial

No prior trial on at least one generic wakefulness agent (e.g., modafinil, armodafinil) may trigger denial for Sunosi; include prior wakefulness agent details in the PA.

• Provide agent name(s), dates, and outcomes for prior wakefulness treatments.

Denial risk if specified prior trials not documented

Coverage may be denied if the member has not had the specified prior trial(s) required by a medication's step therapy criteria; providers must document prior trials (agents, dates, outcomes).

• Follow each criteria section exactly and supply chart evidence of prior trials to avoid denials.

Ophthalmic agents denial risk without prostaglandin analog trial

A prior trial of latanoprost, bimatoprost, or Lumigan must be documented to meet step therapy for the listed ophthalmic medications; absence of this evidence may trigger denial.

• Include which prostaglandin analog was used and treatment dates.

Vaginal estrogen denial risk without generic estradiol trial

A prior trial of generic vaginal estradiol must be documented for IMVEXXY (starter or maintenance) or Premarin cream step‑therapy criteria; lack of documentation may result in denial.

• Provide evidence of generic vaginal estradiol use (agent, dates, and outcome).

Topical acne prior‑therapy documentation required

Documentation of prior topical acne treatment must include the agent name, dates of therapy, and treatment outcome to satisfy step‑therapy requirements.

• Record specific generic topical acne product used, therapy dates, and clinical response on the PA.

Document non‑micronized tretinoin use for adapalene/tazarotene

Documentation of prior use of non‑micronized tretinoin (agent name and dates) is required for adapalene/tazarotene group step‑therapy criteria.

• Specify non‑micronized tretinoin product, dates of use, and clinical outcome.

Required documentation of prior trials for PA

Providers must document prior medication trials specified for each agent (agent names, dates, and outcomes) to meet step‑therapy requirements and support PA approval.

• Include clear chart evidence of failure, intolerance, or contraindication to prior agents when applicable.

Pimecrolimus: document tacrolimus + topical corticosteroid trials

When requesting pimecrolimus, document prior trials of tacrolimus and at least one listed topical corticosteroid (betamethasone, clobetasol, hydrocortisone, triamcinolone).

• Provide agent names, dates, and clinical outcomes for each prior topical used.

Dificid: document prior oral vancomycin trial

When requesting Dificid, include documentation that oral vancomycin was tried (agent, dates, and response) as this is required by the step‑therapy criteria.

• Attach chart notes or prescription history showing oral vancomycin use.

Envarsus: document generic tacrolimus trial

For Envarsus XR requests, document a prior trial of generic tacrolimus (agent, dates, and outcome) to meet step‑therapy requirements.

• Include reason for switching or failure of generic tacrolimus if applicable.

Equetro: document prior generic carbamazepine trial

For Equetro, document prior trial of generic carbamazepine ER or IR (agent name, dates, response) when submitting the PA.

• Specify formulation (ER or IR) used and treatment outcome.

Femring: document estradiol cream trial

For Femring requests, include documentation of prior estradiol cream use (agent, dates, and outcome) as required by step therapy.

• Attach prior treatment records demonstrating estradiol cream use.

Umeclidinium: document Spiriva trial

For Umeclidinium Ellipta, documentation of prior Spiriva use is required before coverage; include Spiriva agent, dates, and response.

• Chart evidence of Spiriva treatment should accompany the PA.

NEUAC: document prior clindamycin‑BPO 1.2%–5% use

Documentation of prior clindamycin‑BPO 1.2%–5% use (product, concentration, dates, outcome) is required for NEUAC medications subject to step therapy.

• Ensure concentration falls within the 1.2%–5% range when documenting prior use.

SGLT2 documentation: two prior agent trials required

For SEGLUROMET/STEGLATRO, chart evidence of prior trials on two of the listed SGLT2 inhibitors must be provided with the PA.

• List the two SGLT2 agents used and therapy dates in the documentation.

Olopatadine: document azelastine nasal spray trial

Olopatadine HCl 0.6% solution coverage requires documentation of a prior trial on azelastine nasal spray; include agent name, dates, and response.

• Attach prior treatment record for azelastine nasal spray when submitting PA for olopatadine.

Pramipexole ER: document IR trial

Pramipexole ER coverage requires documentation of pramipexole immediate‑release therapy; include dates and clinical outcome.

• Show pramipexole IR treatment history and reason for escalation to ER formulation.

Prucalopride: document Linzess trial

Document prior Linzess therapy when requesting prucalopride; the PA must include Linzess agent, dates, and response.

• Failure to document Linzess may result in denial for prucalopride succinate.

Qelbree: document atomoxetine + guanfacine/clonidine trials

For Qelbree, document prior trials of atomoxetine AND either guanfacine or clonidine (agent names, dates, and outcomes).

• PA should clearly show both required prior agents were tried.

Rasuvo: document generic methotrexate trial

Document prior trial of generic methotrexate when requesting Rasuvo; include dates and treatment response.

• Attach evidence of methotrexate use in the chart or pharmacy history.

Soolantra: document prior azelaic acid or metronidazole trial

For Soolantra (ivermectin 1% cream), document a prior trial of azelaic acid or topical metronidazole (agent, dates, outcome) with the PA.

• Specify which topical was used and the clinical response in the documentation.

Pitavastatin: document prior generic statin trial

Document prior trial of at least one listed statin when requesting pitavastatin calcium; include agent, dates, and reason for switch or failure.

• Examples of listed statins include atorvastatin, fluvastatin IR, lovastatin, pravastatin, rosuvastatin, simvastatin.

Stimulants: document prior alternative stimulant (exception noted)

For lisdexamfetamine or methylphenidate patch requests, document prior trial of one of the listed alternative stimulants (agent, dates, outcome) unless the diagnosis is binge‑eating disorder.

• If the diagnosis is binge‑eating disorder, note that the step requirement does not apply.

Sunosi: document prior modafinil/armodafinil trial

Document prior trial of at least one generic wakefulness agent (e.g., modafinil or armodafinil) when requesting Sunosi; include agent, dates, and response.

• Attach pharmacy history or chart evidence of the prior wakefulness agent trial.

Required documentation: prior agents, dates, and outcomes

Documentation should show the prior medication trials and products used (specific agents listed in each criteria) to meet step‑therapy requirements for approval.

• Include agent names, start/stop dates, and clinical outcome (failure, intolerance, or contraindication).