2026 Step Therapy Criteria — select CNS agents (antidepressants, antipsychotics, dextromethorphan/bupropion, trazodone)
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Defines Meridian Health Plan step therapy requirements for selected antidepressants, oral antipsychotics, dextromethorphan/bupropion products (Auvelity/Exxua), and trazodone; applies to prior authorization and coverage decisions for affected pharmacy products under Meridian's 2026 policy.
No material clinical or coverage changes in this revision.
Coverage Criteria — Step Therapy Rules
Antidepressant Step Therapy
Antidepressants — Step therapy rules
Step 1 drugs include bupropion SR/XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine IR/ER; Exxua may be approved without prerequisites for patients with suicidal ideation or if the patient is currently taking or has previously taken Exxua.
Oral Antipsychotic Step Therapy
Oral antipsychotics — Step therapy rules
Step 1 drugs include oral formulations of aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, or ziprasidone. A brand-name equivalent trial counts. Approve Fanapt if the patient is currently taking Fanapt or has taken Fanapt in the past.
Dextromethorphan/Bupropion Step Therapy
Dextromethorphan/Bupropion (Auvelity/Exxua) — Step therapy rules
Exceptions: approve Auvelity without prerequisite trials for current suicidal ideation, for agitation associated with dementia due to Alzheimer's disease, or if the patient is currently taking or has previously taken Auvelity.
Otherwise follow Step 1 drug trial rules per the antidepressant section.
Trazodone Step Therapy
Trazodone — Step therapy rules
Tablet strengths referenced include 50 mg, 100 mg, and 150 mg.
Step therapy criteria for Raldesy
Covered when ALL of the following step-based conditions are met:
Tablet strengths referenced: 50 mg, 100 mg, 150 mg.
Per the Auvelity step-therapy rules, coverage for Auvelity may be approved without prerequisite drug trials when the request is for agitation associated with dementia due to Alzheimer’s disease. This mirrors other listed exceptions (for example, current suicidal ideation or current/prior Auvelity use) that allow bypassing the usual SSRI/SNRI + bupropion trial requirement described for Auvelity.
This portion of the policy does not list any additional explicit exclusions for the covered products in these sections.
No not-medically-necessary (NMN) statements are specified in this section of the policy.
Operational Parameters & Lookback
Provider Requirements, Prior Authorization & Documentation
PA requires documented Step trials or an exception
Prior authorization requires submission of evidence that the required prior Step medication trials were completed (timing and products as specified in the applicable section) or documentation of an accepted exception (for example: current suicidal ideation, current/prior use of the requested product, or agitation associated with Alzheimer’s disease).
- Evidence must show the specific Step drug(s) tried and timing within the prior 180 days where required.
PA for Raldesy requires meeting step criteria or documented exception
For Raldesy, prior authorization is granted only when step-therapy criteria are met — i.e., a prior trial of a tablet dosage form of generic trazodone (with at least a 1-day supply in the prior 180 days) — or when a documented reason to bypass the tablet trial is provided (difficulty swallowing, current or prior Raldesy use).
- Approval also allowed if the patient is currently taking Raldesy or has taken it in the past, or cannot swallow tablets.
Document trials of listed Step 1 (and Step 2 where noted) products
Providers must document trials of the listed Step 1 products (and Step 2 where applicable) described in each section before coverage of higher-step or brand products will be approved, subject to specified exceptions.
- Step 1 antidepressant list includes bupropion SR/XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine IR/ER (one trial within prior 180 days).
- Auvelity requires trial of a generic SSRI or SNRI AND bupropion within prior 180 days unless exception applies.
- Oral antipsychotics require two distinct Step 1 trials within prior 180 days for Step 2 approval.
Two-step sequence: generic trazodone tablets then Raldesy
Trazodone uses a two-step sequence: Step 1 requires a trial of a generic trazodone tablet formulation (50 mg, 100 mg, or 150 mg); Step 2 is Raldesy oral solution and may be approved only after Step 1 is met or an exception is documented.
- Step 1 tablet strengths referenced include 50 mg, 100 mg, 150 mg.
- Step 2 is Raldesy 10 mg/mL oral solution and requires Step 1 evidence or bypass justification.
Document drug name and ≥1-day supply within prior 180 days when required
When documenting prior trials or exceptions for PA, include the drug name and evidence of at least a 1-day supply within the prior 180 days where required; also document current or prior use of the requested product when that is the basis for approval.
- Record the specific drug product and dispensing or administration dates demonstrating ≥1-day supply in the prior 180 days.
- If relying on continuation/prior-use exception, document that the patient is currently taking or previously took the requested product.
Support must show tablet-form trazodone trial or documented exception for Raldesy
For Raldesy-specific support, document a trial of a tablet dosage form of generic trazodone (≥1-day supply within the prior 180 days) OR document an allowed reason to bypass the tablet trial such as documented difficulty swallowing tablets, current use of Raldesy, or prior use of Raldesy.
- Tablet trial is satisfied by evidence of at least a 1-day supply in the prior 180 days.
- Acceptable alternative documentation: difficulty swallowing tablets, current Raldesy use, or prior Raldesy use.
Coverage may be denied if required Step trial history within 180 days is not documented
If the required number and type of prior Step drug trials within the prior 180 days are not documented (for example, one Step 1 trial for certain antidepressants or two distinct Step 1 trials for oral antipsychotics), coverage may be denied.
- Denial risk applies when requisite trials within the prior 180 days are missing and no exception is documented.
- Examples: one Step 1 trial missing for antidepressant prerequisites; two distinct Step 1 trials missing for antipsychotic prerequisites.
Prior tablet trazodone trial (≥1-day in prior 180 days) or exception required for Raldesy
Coverage for Raldesy requires documentation of a prior trial of a tablet dosage form of generic trazodone with at least a 1-day supply in the prior 180 days, or documentation of an exception (difficulty swallowing, current/prior Raldesy use). Absence of this tablet trial documentation may trigger denial.
- Tablet trial defined as ≥1-day supply within prior 180 days.
- Exceptions that permit approval without tablet trial: inability to swallow tablets, current or prior use of Raldesy.
Background & Policy Scope
This policy section defines Meridian’s operational step-therapy approach for selected CNS agents. It organizes agents into Step 1 and Step 2 groups and requires documented trials of lower-step products before approving higher-step or brand products, subject to specified exceptions. For Auvelity (dextromethorphan/bupropion) the standard requirement is a trial of a generic SSRI or SNRI AND bupropion within the prior 180 days, but coverage may be granted without those prerequisites for current suicidal ideation, if requested for agitation associated with dementia due to Alzheimer’s disease, or if the member is currently taking or has previously taken Auvelity. For trazodone products, the policy distinguishes generic trazodone tablets (Step 1) from Raldesy oral solution (Step 2) and requires a documented tablet trial (≥ a 1-day supply in the prior 180 days) unless the member has difficulty swallowing tablets or is a current/prior Raldesy user.
Definitions & Exceptions
Initial Therapy — Step 1 Product Groups
Initial therapy Step 1
Initial Step 1 product groups
See policy product lists for specific strengths and formulations.
See policy product lists for specific agents and strengths.
At least a 1-day supply within prior 180 days counts as a trial where specified.
Initial therapy
Initial step
A tablet trial is defined as ≥1-day supply in the prior 180 days.
Continuation / Prior Use Criteria
Continuation / Prior Use
Continuation or ongoing therapy allowances
Documentation of current or prior use satisfies step requirement per respective sections.
Step Therapy Tables — Required Trials by Product
| Step | Requirement | Notes / Exceptions |
|---|---|---|
| Step 1 | One Step 1 drug trial with at least a 1-day supply within the prior 180 days is required before approving higher-step antidepressant products. | Step 1 drugs include bupropion SR/XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, or venlafaxine IR/ER. Exxua may be approved without prerequisite trials for patients with current suicidal ideation or if the patient is currently taking or has previously taken Exxua. |
| Step | Requirement | Notes / Exceptions |
|---|---|---|
| Step 2 (oral antipsychotic) | Coverage requires two distinct Step 1 drug trials, each with at least a 1-day supply within the prior 180 days, before approving Step 2 oral antipsychotics (e.g., Fanapt). | Step 1 drugs include listed oral formulations such as aripiprazole, asenapine, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, xanomeline/trospium, or ziprasidone. Approve if patient is currently taking Fanapt or has taken Fanapt in the past. |
| Step | Requirement | Notes / Exceptions |
|---|---|---|
| Step 2 (Auvelity) | Prior to approving Auvelity, the patient must have trialed a generic SSRI or SNRI AND bupropion for any trial duration within the previous 180 days. | Exceptions: approve Auvelity without prerequisite trials for patients with current suicidal ideation, for agitation associated with Alzheimer's dementia, or if the patient is currently taking or has previously taken Auvelity. Follow antidepressant Step 1 drug list for eligible SSRI/SNRI and bupropion products. |
| Step | Requirement | Notes / Exceptions |
|---|---|---|
| Step 1 / Step 2 | Trazodone products are organized into Step 1 (generic trazodone tablets) and Step 2 (Raldesy oral solution). | Step 1 lists trazodone 100 mg and 150 mg tablets; Step 2 is Raldesy 10 mg/mL oral solution. No additional trial logic provided beyond the tablet-to-Raldesy sequence in this section. |
| Step | Requirement | Notes / Exceptions |
|---|---|---|
| Step 1 | Patient must have trialed a tablet dosage form of generic trazodone (any listed tablet strength) with at least a 1-day supply in the prior 180 days to meet the Step 1 requirement. | Tablet strengths referenced include 50 mg, 100 mg, and 150 mg. Documentation should show at least a 1-day supply within the prior 180 days. If the Step 1 tablet trial is met, proceed to consider Raldesy per Step 2 criteria. |
| Step 2 (Raldesy) | Approve Raldesy 10 mg/mL oral solution if the Step 1 tablet trial is met, or if the patient has difficulty swallowing tablets, is currently taking Raldesy, or has taken Raldesy at any time in the past. | Documentation may include inability to swallow tablets, current use, or prior use of Raldesy as reasons to approve without an additional tablet trial beyond the requirements stated. |
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