Step Therapy Criteria for Select Pharmacy Drugs (AUVELITY and others)
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Defines step therapy and automatic approval requirements for specified drugs for Integrated Home Care Services members; impacts prescribers and pharmacy prior authorization processes.
No material clinical or coverage changes in this revision.
Coverage Criteria — Step Therapy and Prior Treatment Rules
Anticoagulant prior therapy or age exception
Apixaban (Eliquis/Eliquis Sprinkle) and Rivaroxaban (Xarelto): Covered when ONE of the following is met
automatic approval when met
Fenofibrate prior therapy requirement
Fenofibrate micronized: Covered when BOTH of the following are met
automatic approval when both met
Fluvastatin prior therapy requirement
Fluvastatin: Covered when ALL of the following are met
automatic approval when met
Seizure medication prior therapy requirement
Levetiracetam-containing products (including Spritam): Covered when ALL of the following are met
automatic approval when met
Ophthalmic prior therapy requirement
Rhopressa and Rocklatan: Covered when ONE of the following is met
automatic approval when met
Tramadol prior therapy requirement
Tramadol: Covered when ONE of the following is met
automatic approval when met
Zypitamag prior therapy requirement
Zypitamag: Covered when ONE of the following is met
automatic approval when met
For Auvelity, the policy notes an explicit exception: the step therapy prerequisite is not required for members with agitation associated with dementia due to Alzheimer’s disease. This exception means prescribers do not need to document trials or inability to use the listed generic antidepressant options for those members when requesting Auvelity.
Provider Actions, Documentation & Automatic Approval Conditions
Auvelity prior therapy requirement
Automatic approval is granted when the member has tried or cannot use a generic SSRI (citalopram, fluoxetine, paroxetine, or sertraline), a generic SNRI (venlafaxine or duloxetine), a generic bupropion product (75mg/100mg IR; 100mg/150mg/200mg SR; or 150mg/300mg XL), or mirtazapine. For Auvelity requests this criterion is not required for members with agitation associated with dementia due to Alzheimer's disease.
- Document trial or documented inability to use one of the listed generic SSRIs, SNRIs, bupropion formulations, or mirtazapine for automatic approval.
Trintellix prior therapy requirement
Automatic approval is granted when the member has tried or cannot use a generic SSRI (citalopram, fluoxetine, paroxetine, or sertraline), a generic SNRI (venlafaxine or duloxetine), a generic bupropion product (75mg/100mg IR; 100mg/150mg/200mg SR; or 150mg/300mg XL), or mirtazapine. The same prior-therapy exception that applies to Auvelity (see Auvelity criteria) is noted.
- Document trial or documented inability to use one of the listed generic SSRIs, SNRIs, bupropion formulations, or mirtazapine for automatic approval.
Oral anticoagulant prior therapy or age-based approval
Automatic approval for apixaban (Eliquis/Eliquis Sprinkle) or rivaroxaban (Xarelto) is given when the member has had previous treatment, a contraindication, or intolerance with the reference tablet product, or when the member is 17 years of age or younger.
- For Eliquis/Eliquis Sprinkle: prior treatment, contraindication, or intolerance with Eliquis (apixaban) tablets OR age ≤ 17.
- For Xarelto/rivaroxaban: prior treatment with Xarelto/rivaroxaban tablets OR age ≤ 17.
Prostaglandin analog prior therapy
Automatic approval for Rhopressa or Rocklatan requires prior treatment with, or a documented contraindication or intolerance to, a prostaglandin analog.
- Document prior therapy with a prostaglandin analog or documentation of contraindication/intolerance for automatic approval.
Fluvastatin prior statin + ezetimibe requirement
Automatic approval for fluvastatin is granted when the member has had previous treatment with ezetimibe and one of the listed statins (lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin).
- Document prior treatment with ezetimibe and one listed statin to meet the requirement for automatic approval.
Zypitamag prior statin requirement
Automatic approval for Zypitamag is granted when the member has had previous treatment with one of the following statins: simvastatin, pravastatin, lovastatin, atorvastatin, or rosuvastatin.
- Document prior treatment with one of the listed statins for automatic approval.
Tramadol prior IR tramadol requirement
Automatic approval for tramadol is granted when the member has had previous treatment with immediate‑release tramadol 50 mg tablet.
- Document prior treatment with IR tramadol 50 mg tablet for automatic approval.
Auvelity step requirement
Prior to approval, require a trial or documentation that the member cannot use a generic SSRI (citalopram, fluoxetine, paroxetine, or sertraline), a generic SNRI (venlafaxine or duloxetine), a generic bupropion product (75mg/100mg IR; 100mg/150mg/200mg SR; or 150mg/300mg XL), or mirtazapine. Exception: not required for members with agitation associated with dementia due to Alzheimer's disease.
- Record trial details or documented intolerance/contraindication to one of the specified agents before approving Auvelity.
Trintellix step requirement
Trintellix follows the same step therapy requirement as Auvelity: require trial or documented inability to use the listed generic SSRIs, SNRIs, specified bupropion products, or mirtazapine.
- Apply the same documentation of trial or intolerance as required for Auvelity when requesting Trintellix.
Antidepressant trial or intolerance documentation
Document that the member tried or cannot use the listed generic antidepressants (SSRIs, SNRIs, specified bupropion formulations, or mirtazapine) or provide evidence of contraindication or intolerance as applicable.
- Include medication names, dates of trial, reason for discontinuation (e.g., intolerance, adverse effect, contraindication) in the prior‑auth request.
Seizure therapy history
For levetiracetam-containing products (including Spritam), provide evidence of prior therapy with levetiracetam and one of the following: lamotrigine, carbamazepine, topiramate, divalproex, or phenytoin to support automatic approval.
- Document prior medications and timeframes showing levetiracetam plus one listed antiepileptic were used.
Prerequisite therapy required
Requests may be denied if the member has not tried or cannot use the specified prerequisite therapies when required (for example, the generic SSRI/SNRI, bupropion formulations, or mirtazapine for Auvelity/Trintellix).
- Ensure required prior‑therapy trials or documented contraindications/intolerances are included to avoid denial.
Prior fenofibrate treatment required
Fenofibrate micronized requires prior treatment with one strength of a generic fenofibrate tablet (145 mg, 160 mg, 48 mg, or 54 mg) AND one strength of a generic fenofibrate micronized capsule (200 mg, 134 mg, or 67 mg) for automatic approval.
- Provide records showing prior use of both a generic fenofibrate tablet strength and a micronized capsule strength.
Initial Therapy — Drug-specific Step Requirements
Oral anticoagulant initial therapy
Eliquis/Eliquis Sprinkle/Xarelto/rivaroxaban initial rules
automatic approval when met
Step Therapy Tables — Required Prior Agents
| Drug | Step therapy requirement |
|---|---|
| Auvelity | |
| Trial or documented inability to use a generic SSRI (citalopram, fluoxetine, paroxetine, or sertraline), a generic SNRI (venlafaxine or duloxetine), a generic bupropion product (75/100 mg IR, 100/150/200 mg SR, or 150/300 mg XL), or mirtazapine; exception: not required for members with agitation associated with dementia due to Alzheimer's disease. |
| Drug | Step therapy requirement |
|---|---|
| Trintellix | |
| Trial or documented inability to use a generic SSRI (citalopram, fluoxetine, paroxetine, or sertraline), a generic SNRI (venlafaxine or duloxetine), a generic bupropion product (75/100 mg IR, 100/150/200 mg SR, or 150/300 mg XL), or mirtazapine. |
| Drug | Step therapy requirement |
|---|---|
| Fenofibrate micronized | |
| Member must have had previous treatment with one strength of generic fenofibrate tablet (145 mg, 160 mg, 48 mg, or 54 mg) AND one strength of generic fenofibrate micronized capsule (200 mg, 134 mg, or 67 mg). |
| Drug | Step therapy requirement |
|---|---|
| Levetiracetam (including Spritam) | |
| Member must have had prior therapy with levetiracetam AND one of the following: lamotrigine, carbamazepine, topiramate, divalproex, or phenytoin. |
Background and Definitions
This policy lists step therapy and automatic-approval rules that link specified specialty or brand drugs to required prior therapies, documented contraindications or intolerances, or defined exceptions to guide prior authorization decisions. For example, Auvelity is eligible for automatic approval when the member has tried or cannot use a generic SSRI (citalopram, fluoxetine, paroxetine, sertraline), a generic SNRI (venlafaxine, duloxetine), a specified generic bupropion formulation (75/100 mg IR; 100/150/200 mg SR; 150/300 mg XL), or mirtazapine — except where a stated exception (agitation associated with Alzheimer’s dementia) applies.
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