Oral Antipsychotics Step Therapy (ANTIPSYCHOTICS - ORAL - PST)
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Step therapy rules governing coverage of specified oral antipsychotic and related CNS drugs for Meridian Health Plan of Michigan members; defines Step 1 and Step 2 product lists and the trial requirements to approve Step 2 agents.
No material clinical or coverage changes in this revision.
Coverage Criteria
Step 1 trial requirement for Fanapt/Opipza
Approve the requested Step 2 antipsychotic (Fanapt or Opipza) when the following is met:
A trial of the brand‑name equivalent of a generic Step 1 product counts toward this requirement.
Auvelity approval criteria
Approve Auvelity when ONE of the following is met:
Explicit allowance for suicidal ideation to bypass Step 1 trial requirement.
Provider Actions & Documentation Requirements
Document two Step 1 oral antipsychotic trials for Fanapt/Opipza
Require documentation that the member has tried two distinct Step 1 oral antipsychotics (or provide evidence the member is currently taking or has previously taken the requested Step 2 drug) to authorize Fanapt or Opipza.
- Two distinct Step 1 oral antipsychotic trials are required (brand-name of a generic Step 1 product counts).
- Alternatively, approval may be granted if the patient is currently taking or has taken the requested Step 2 drug (Fanapt or Opipza) in the past.
SSRI/SNRI plus separate bupropion trial required for Auvelity
Require documentation of a prior trial of a generic SSRI or SNRI and a separate trial of bupropion to approve Auvelity, unless the patient meets an exception (current or prior Auvelity use, or suicidal ideation).
- Document trial of a generic SSRI OR SNRI AND a separate trial of bupropion.
- If the patient has suicidal ideation, or is currently taking/has taken Auvelity, the SSRI/SNRI + bupropion trials are not required for approval.
Two-step therapy structure (Step 1 → Step 2)
This program uses a two-step structure: drugs are assigned to Step 1 (preferred) or Step 2 (non-preferred); Step 2 coverage generally requires prior trials of Step 1 agents as specified in the criteria.
- Step 1 lists include multiple oral antipsychotics and related CNS agents (see Step 1 product lists).
- Step 2 lists include non-preferred agents such as Fanapt and Auvelity; Step 2 approval requires meeting the specific prior-trial requirements in the policy.
Document evidence of two Step 1 trials for Fanapt/Opipza
Provide documentation of two Step 1 oral antipsychotic trials (or evidence the member is currently/previously taking the requested Step 2 drug) to meet approval criteria for Fanapt or Opipza.
- Include medication name, dosing, dates of trial, and outcome or reason for discontinuation when available.
- A trial of the brand-name equivalent of a generic Step 1 product counts toward the requirement.
Failure to document Step 1 trials may prevent Step 2 approval
When Step 2 agents are requested (e.g., Fanapt, Opipza), the provider must document failure or trial of Step 1 agents — failure to do so may result in denial of the Step 2 drug request.
- If trials of two distinct Step 1 oral antipsychotics are not documented and no current/prior use of the requested Step 2 drug is shown, authorization may be denied.
Required documentation for Auvelity requests
Document prior trial of a generic SSRI or SNRI AND a separate trial of bupropion, or document that the patient is currently taking or has previously taken Auvelity, or document presence of suicidal ideation when requesting Auvelity without the SSRI/SNRI + bupropion trials.
- Include medication names, dates, and outcomes for SSRI/SNRI and bupropion trials.
- If asserting the suicidal ideation exception, include clinical documentation supporting that presentation.
Step 1 trial requirement for certain Step 2 drugs — denial risk
Certain Step 2 drugs (Fanapt, Opipza) require documented trials of two Step 1 oral antipsychotics; absence of this documentation may lead to denial of the Step 2 request unless the patient is currently or was previously taking the requested Step 2 agent.
- Ensure records show two distinct Step 1 drug trials or evidence of current/prior Step 2 use to avoid denial.
Step Therapy Requirements
| Requirement | Details / Documentation | Coverage |
|---|---|---|
| Documented trials of two distinct Step 1 drugs | Patient must have tried two Step 1 oral antipsychotics (oral formulations listed in policy such as aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, or ziprasidone). A trial of the brand‑name equivalent of a generic Step 1 product counts. Record drug names and trial dates. | covered_with_criteria |
| OR — Current or prior use of the requested Step 2 drug | If the patient is currently taking or has taken the requested Step 2 agent (Fanapt or Opipza) in the past, document prior/current use instead of two Step 1 trials. | covered_with_criteria |
| Requirement | Details / Documentation | Coverage |
|---|---|---|
| Trial of a generic SSRI or SNRI plus a separate trial of bupropion | Patient must have tried a generic SSRI OR SNRI and separately tried bupropion. Document agents used and trial dates (examples of SSRI/SNRI and bupropion products are listed in the Step 1 and Step 2 product lists). | covered_with_criteria |
| Exceptions: suicidal ideation or prior/current Auvelity use | Auvelity may be approved without the SSRI/SNRI + bupropion trials if the patient has suicidal ideation, or if the patient is currently taking or has taken Auvelity in the past. Document rationale or prior/current use accordingly. | covered_with_criteria |
Definitions
Background
This policy implements a two‑step step‑therapy approach for specified oral antipsychotic and related central nervous system agents. Products are organized into Step 1 (preferred) and Step 2 (non‑preferred) lists. For most Step 2 agents (for example, Fanapt and Opipza), coverage requires documentation that the member has tried two distinct Step 1 oral antipsychotics, or evidence that the member is currently taking or has previously taken the requested Step 2 drug. A brand‑name trial that is equivalent to a generic Step 1 product counts toward the two‑trial requirement.
Auvelity (dextromethorphan/bupropion) is handled with a separate, specific pathway: approve when the member has tried a generic SSRI or SNRI AND separately tried bupropion, or when the member is currently taking or has taken Auvelity in the past. The policy also explicitly allows approval of Auvelity without prior Step 1 trials when the member has suicidal ideation.
Revision History
Policy effective date set to 2025-01-01.
Policy reviewed/updated (step therapy criteria and details); document header notes update on 2025-12-01.
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