Step therapy medication list — Pharmacy step therapy coverage criteria
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Defines medications added to the payer's step therapy program and explains requirements for trying lower-cost (step 1) agents before coverage of higher-cost (step 2) agents; affects prescribers, pharmacists, and members under Hometown Health prescription drug benefits.
No material clinical or coverage changes in this revision.
Step Therapy Coverage Criteria
Initial step therapy coverage criterion
Covered when ALL of the following are met
Pharmacy claims will be checked; pharmacist may contact prescriber if criteria not met.
Step therapy requirements may differ by plan. Step therapy requirements may vary by benefit plan; some plans or members may be subject to different rules or exemptions. Always confirm the member's specific benefit design before assuming step therapy applies.
Provider Actions and Enforcement
Prior authorization and quantity limits may affect coverage
Additional clinical programs may apply to medications on this list and can change coverage. Providers should expect that quantity limits and prior authorization requirements may exist for step therapy agents and can affect whether a prescription is covered.
- Check member benefit and pharmacy plan rules for applicable prior authorization and quantity limits.
- Prior authorization or quantity limits may prevent coverage even if step therapy is satisfied.
Try required step 1 medication(s) before prescribing step 2
Members must have tried the designated step 1 medication(s) listed for the clinical condition before a step 2 medication will be covered; the policy lists step 1 and step 2 agents by therapeutic class and condition.
- For each condition or drug class, confirm the required step 1 agent(s) are documented or visible in pharmacy claims before prescribing step 2 agents.
- See the per-class lists in the policy for the exact step 1 and step 2 agents (e.g., VANDAZOLE is step 2 for bacterial vaginosis; generic doxycycline/minocycline are step 1 for some tetracycline classes).
Document prior step 1 trials and confirm timing/effective date
Pharmacy claims are checked for prior use of required step 1 medications; step therapy requirements take effect Jan. 1, 2026 and may vary by benefit plan, so confirm member-specific rules and effective dates when documenting treatment.
- Documentation/timing: Ensure prior trials of step 1 agents are recorded in the medical record or reflected in pharmacy claims prior to dispensing a step 2 medication.
- Verify the member's benefit plan for exemptions or differing requirements, since step therapy requirements may vary by plan.
Failure to document step 1 trial can result in denial or non-dispense
Coverage of a step 2 medication may be denied or the medication may not be dispensed if pharmacy claims do not show a prior trial of the required step 1 medication; pharmacists will contact the prescriber to explain next steps when criteria are not met.
- If pharmacy claims lack evidence of step 1 use, expect a denial at point of sale or pharmacist outreach to the prescriber.
- Address denials by providing documentation of prior step 1 therapy or pursuing prior authorization if available.
Program Background
Step therapy is a utilization management program that requires members to try lower‑cost, clinically appropriate medications before higher‑cost alternatives are covered. The payer implemented these step therapy requirements effective Jan. 1, 2026. Bold type in the drug lists indicates brand‑name products and plain type indicates generics. The list of step therapy medications is subject to change without notice, and additional clinical programs such as prior authorization and quantity limits may also apply and affect prescription coverage.
Formatting and Definitions
Initial (Step 1) Therapy Criteria
Step 1 (Initial) therapy
Initial (Step 1) therapy requirements
Specific required step 1 agents and numeric requirements (e.g., any one of, any two of, both of the following) vary by class and are listed in the step therapy tables; pharmacy claims will be checked for prior use.
Step Therapy Drug Lists
| Therapeutic class / condition | Step 1 (required trial) | Step 2 (requires prior Step 1 trial) |
|---|---|---|
| Bacterial Vaginosis | Any one of the following generics: clindamycin 2% vaginal cream; metronidazole 0.75% vaginal gel; metronidazole tablet; tinidazole tablet | VANDAZOLE |
| Tetracyclines (oral) | Both of the following generics: doxycycline AND minocycline | VIBRAMYCIN SEYSARA |
| Antilipemic (statins/fibric acids) | Any one of the following generics: atorvastatin, fluvastatin (IR/ER), lovastatin, pravastatin, rosuvastatin, simvastatin; OR fenofibric formulations (fenofibric cap/tab/micronized) | ALTOPREV; EZALLOR; FLOLIPID; REPATHA; FENOGLIDE; FIBRICOR |
| Antidepressants | Generic bupropion ER or any two of the following generics (examples listed): desvenlafaxine ER, duloxetine, venlafaxine IR/ER, bupropion, citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine IR/ER, sertraline | APLENZIN; FETZIMA; DESVENLAFAXINE ER; TRINTELLIX; others listed |
| Antipsychotics | Any two of the following generics: aripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine IR/ER, risperidone, ziprasidone | VIIBRYD; CAPLYTA; COBENFY; FANAPT; OPIPZA; INVEGA HAFYERA (listed as Step 2 brands) |
| Dermatology – Rosacea / Topicals | Any one of the following generic or preferred brands: azelaic acid gel; FINACEA FOAM; SOOLANTRA; generic tacrolimus ointment; listed topical generics | FINACEA GEL; ZILXI; ZORYVE (0.15%/0.3% noted) |
| Ophthalmology – Antiglaucoma | All of the following generics and preferred brand: latanoprost AND travoprost AND LUMIGAN | XELPROS |
| Epinephrine auto-injectors (long-acting) | Generic epinephrine | EPIPEN |
| Diabetic agents | Any one of the following generics: metformin IR/ER; combinations like glipizide‑metformin, glyburide‑metformin; pioglitazone‑metformin | CYCLOSET; RIOMET |
| Gastroenterology – Constipation agents / PPI / Miscellaneous | Any one of the following generics: lactulose; polyethylene glycol; preferred generics for PPI class (dexlansoprazole, esomeprazole, omeprazole, lansoprazole, pantoprazole) as applicable | LINZESS; prucalopride; SYMPROIC; MOTEGRITY; FIRST‑OMEPRAZOLE (and other brand formulations listed) |
Quantity Limits and Related Notes
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