MESSA Prior Auth & Step Therapy Coverage

Medication Coverage Criteria

Drug-specific coverage criteria

Covered when the applicable diagnosis, age or weight, laboratory or diagnostic findings, prior-treatment requirements, safety restrictions, and benefit requirements are met.

Iron, dermatology, sexual-health, and ADHD therapies: Accrufer: iron deficiency, age ≥10 years, and failure or intolerance to two over-the-counter iron products. Adbry: moderate-to-severe atopic dermatitis, age ≥12 years, failure of a listed high-potency topical or systemic therapy, and no same-indication biologic or targeted DMARD. Addyi: female age ≥18 and <65 with acquired generalized HSDD lasting >6 months after other causes are ruled out. Adzenys ER or amphetamine ER ODT: ADHD, age ≥6 years, failure or intolerance to generic methylphenidate and generic amphetamine therapy, or inability to swallow solid dosage forms with failure of a sprinkle-capable alternative.

Hemophilia and hereditary angioedema pathways: Alhemo, Hemlibra, Hympavzi, or Qfitlia may be covered for the applicable congenital hemophilia A or B prophylaxis pathway with specialist and hemophilia-treatment-center care, factor VIII or IX deficiency or inhibitor documentation, bleeding history, and required prior therapy. Andembry, Haegarda, Orladeyo, Takhzyro, Dawnzera, Firazyr, or Ruconest require laboratory-confirmed HAE, qualifying attack frequency or severity, specialist prescribing where stated, and avoidance of duplicate HAE therapy; acute-attack products require the applicable acute-attack pathway.HAE generally requires ≥2 attacks/month or severe facial, throat, or gastrointestinal attacks; factor VIII or IX <1% indicates severe disease and 1%-5% moderate disease; inhibitor titer >5 BU/mL is high titer.

Rare disease, metabolic, and hepatobiliary therapies: Aqneursa or Aqvesme: neurologic Niemann-Pick type C with specified genetic or biomarker confirmation and age or weight eligibility. Aqvesme thalassemia: genetically confirmed alpha- or beta-thalassemia with the applicable non-transfusion-dependent or transfusion-dependent pathway and hemoglobin or transfusion criteria. Arcalyst: CAPS, DIRA, or recurrent pericarditis pathway. Bylvay or Livmarli: PFIC or ALGS cholestatic pruritus pathway with transplant, cirrhosis, age, diagnostic, ursodiol, and, when applicable, Livmarli or Bylvay prerequisites. Cerdelga, Chenodal, Cholbam, Ctexli, Carbaglu, miglustat, Loargys, Galafold, Iqirvo, and related therapies require their disease-specific genetic, enzyme, biopsy, laboratory, specialist, and prior-treatment criteria.

Pulmonary, respiratory, and cystic-fibrosis therapies: Alyftrek, Symdeko, Trikafta, Orkambi, Bronchitol, Cayston, Tobi Podhaler, Brinsupri, Glassia, Fasenra, Nucala, Dupixent, Tezspire, Ohtuvayre, nintedanib, Jascayd, and pulmonary-hypertension therapies are covered only for their listed CFTR-responsive cystic-fibrosis, bronchiectasis, alpha-1-antitrypsin deficiency, eosinophilic or type 2 airway disease, interstitial-lung-disease, or pulmonary-hypertension indications with the required age, laboratory, severity, controller-therapy, and step-therapy criteria.Examples include Alyftrek age ≥6 years; Bronchitol age ≥18 years with a passed tolerance test; Brinsupri age ≥12 years with ≥2 adult or ≥1 pediatric exacerbation in 12 months; Glassia FEV1 35%-60% predicted and low AAT; Dupixent eosinophilic asthma eosinophils ≥150/µL and COPD eosinophils ≥300/µL.

Immunology and rheumatology therapies: Cibinqo, Cimzia, Cosentyx, Enbrel, Entyvio, Kevzara, Kineret, Nemluvio, Olumiant, Orencia SC, Otezla/Otezla XR, Rinvoq/Rinvoq LQ, Sotyktu, Taltz, Tremfya, Tyenne, adalimumab, Simponi, Skyrizi, tofacitinib, and related biologics or targeted therapies require a listed diagnosis, indication-specific age or weight, and the specified topical, DMARD, biologic, targeted-therapy, NSAID, corticosteroid, or other treatment failures. Same-indication biologic or targeted-DMARD combination therapy is excluded where stated.Some inflammatory-disease pathways require a DMARD trial of at least 3 months and failure of two to four listed advanced therapies.

Neurologic, psychiatric, and seizure therapies: Austedo, Crexont, Daybue, Epidiolex, Evrysdi, Increlex, Imcivree, Nuedexta, Nuplazid, Onapgo, Nourianz, Oxervate, Qelbree, Qulipta, Quviviq, Rytary, topiramate products, Xcopri, Xywav, and related therapies require the stated neurologic or psychiatric diagnosis, age, genetic or diagnostic confirmation, step therapy, and safety criteria. SMA products require genetic confirmation and motor-function assessment; obesity products require genetic diagnosis or qualifying BMI and objective weight response when renewed.

Cardiovascular, endocrine, oncology, and hematology therapies: Camzyos and Myqorzo require symptomatic obstructive HCM, NYHA class, LVEF, LVOT gradient, and failure or intolerance of a maximally tolerated beta blocker or calcium-channel blocker. Ibrance requires the applicable HR-positive breast-cancer indication and CDK4/6 step therapy. Dasatinib, nilotinib, and Tasigna require qualifying Ph-positive CML or ALL pathways and imatinib or dasatinib sequencing. Doptelet and eltrombopag require indication-specific thrombocytopenia, platelet counts, age, prior therapy, and dose limits. Rezdiffra requires noncirrhotic NASH/MASH with F2-F3 fibrosis, diet and exercise, and no alcohol use.Camzyos initial LVEF >55% and LVOT ≥50 mmHg; renewal LVEF ≥50%. Myqorzo initial LVEF ≥55% and LVOT ≥50 mmHg.

Gastrointestinal, renal, reproductive, and weight-management therapies: Contrave, Qsymia, orlistat, Myfembree, Oriahnn, Orilissa, mirabegron, Gemtesa, Gattex, Viberzi, Viokace, Voquezna-like therapy, Tarpeyo, Filspari, Fabhalta, Voyxact, and infertility medications require the applicable diagnosis, age, BMI or weight, laboratory, benefit, prior-treatment, and combination restrictions. Fertility medications are covered only when medically appropriate and included in the member's fertility benefit.Weight-management examples: adult obesity BMI ≥30 kg/m² or BMI ≥27 kg/m² with a comorbidity; continued Contrave or orlistat coverage generally requires maintained 5% weight loss.

Hepatitis C and infectious-disease therapies: Epclusa, sofosbuvir-containing therapy, Harvoni oral pellets, Sovaldi, and Vosevi require the applicable chronic hepatitis C genotype, age or weight, cirrhosis, prior-treatment, preferred-Epclusa, ribavirin, and case-by-case AASLD/FDA-label review. Livtencity requires post-transplant CMV infection or disease, age ≥12 years and weight ≥35 kg, and failure of a listed antiviral. Recurrent C. difficile prevention requires the stated recurrence, positive toxin-test, age, and nonduplication criteria.

Osteoporosis, pulmonary hypertension, amyloidosis, and specialty therapies: Teriparatide, Forteo, and Tymlos require osteoporosis or fracture-risk criteria and the appropriate high-risk or very-high-risk bisphosphonate, zoledronate, or denosumab pathway. Uptravi or Ventavis requires pulmonary arterial hypertension with the specified sildenafil or tadalafil and ambrisentan or bosentan trials, or the PH-ILD pathway. Vyndamax or Vyndaqel requires confirmed wild-type or hereditary ATTR-CM, age ≥18 years, and NYHA class I-III disease. Wainua requires adult hATTR peripheral neuropathy with TTR mutation and staging criteria. Vyvgart Hytrulo requires either antibody-positive MG or diagnostic CIDP with prior standard-of-care failure and no prohibited combination therapy.Tymlos maximum duration is 2 years; Vyvgart Hytrulo MG generally requires ≥12 weeks of ineffective standard-of-care therapy.

Combination restrictions: Adbry, Cibinqo, Dupixent, Ebglyss, Enbrel, Entyvio, Fasenra, Kevzara, Kineret, Litfulo, Nemluvio, Nucala, Olumiant, Orencia SC, Otezla, Otezla XR, Rinvoq, Rinvoq LQ, adalimumab, Simponi, Skyrizi, Sotyktu, Taltz, Tezspire, Tremfya, Tyenne, and Xeljanz products will not be used with another biologic, targeted DMARD, or other prohibited immunosuppressant for the same indication. Cibinqo, Olumiant, Litfulo, Rinvoq, Rinvoq LQ, and Xeljanz also include restrictions on specified potent immunosuppressants. Vyvgart Hytrulo is not covered with another biologic or immunoglobulin therapy for the applicable MG or CIDP indication.

Therapy-specific exclusions: Alyftrek and Trikafta will not be used with another CFTR potentiator, including Orkambi, Kalydeco, or Symdeko. Andembry, Dawnzera, Haegarda, Orladeyo, and Takhzyro will not be used with another HAE prophylaxis product; acute HAE products such as Firazyr and Ruconest will not be combined with another acute-attack product. Alhemo and Hemlibra will not be used with immune tolerance induction. Empaveli and Fabhalta will not be used with Soliris, Ultomiris, or other PNH medications. Evrysdi will not be used with another SMN2-directed therapy or after SMA gene therapy. Galafold will not be used with another molecular chaperone or enzyme replacement therapy for Fabry disease; Loargys will not be used with another enzyme replacement therapy for ARG1 deficiency; Joenja will not be used with an immunosuppressive medication; Kygevvi will not be used with another TK2-deficiency medication; and Rivfloza will not be used with Oxlumo.

Duplicate, interaction, and safety restrictions: Belsomra, Dayvigo, Lumryz, and sodium oxybate/Xyrem are excluded with other sedative-hypnotics, specified CNS depressants, or alcohol. Belbuca, hydrocodone products, Opana ER, and Nucynta ER are not covered with more than one long-acting opioid concurrently. Emgality, Nurtec ODT, and other specified migraine-prevention therapies will not be combined with another CGRP antagonist. Diclofenac 2% and Flector are excluded with concurrent oral NSAID therapy. Orlistat and phentermine/topiramate ER are excluded with other weight-loss products; Ozempic and Trulicity are excluded with another GLP-1 agonist-containing product; and Repatha is excluded with another PCSK9 inhibitor. Iqirvo and Livdelzi are excluded with additional second-line PBC therapy, including another PPAR agonist. Filspari is excluded with a RAS inhibitor or an endothelin receptor antagonist such as Vanrafia. Vyndamax, Vyndaqel, and Wainua are excluded with another transthyretin-amyloidosis therapy.

Indication and benefit exclusions: Certain infertility products, including cetrorelix, Crinone, and ganirelix acetate, are not covered when used for assisted reproductive treatment unless the applicable fertility benefit supports coverage. Selected hepatobiliary therapies require no liver-transplant history or planned transplant and no decompensated cirrhosis; Livmarli specifically requires these conditions. Rezdiffra is not continued after progression to cirrhosis. Imcivree continuation requires at least a 5% reduction in baseline body weight or BMI. Therapy for epidermolysis bullosa wounds is excluded with current or historical malignancy in the treatment area, active infection, prior stem-cell transplant, or prior gene therapy. Recurrent C. difficile prevention therapy is not combined with Zinplava, Rebyota, or another CDI-prevention product. Wainua is excluded when ocular or cerebral manifestations predominate, after liver transplant, or with NYHA heart-failure classification above II. Xolair is not covered with another food-allergy desensitization therapy or another same-indication biologic/targeted DMARD and, for food allergy, requires epinephrine access and an allergen-avoidant diet. Vardenafil and other erectile-dysfunction products are subject to the member's benefit and quantity limits.

Initial Authorization Criteria

Initial therapy criteria

Initial authorization requires one complete product-specific pathway; when a pathway lists alternatives, the alternatives are separated by OR and all criteria within the selected branch must be met.

General initial authorization: Document the requested drug's covered diagnosis, age or weight, disease severity, laboratory or genetic confirmation, specialist or treatment-center requirements, required prior-treatment failures or intolerances, dose or duration limits, and absence of prohibited concomitant therapy.

Preferred and generic sequencing: Complete the applicable step therapy before coverage. Examples include Novolog before Afrezza; two preferred triptans before almotriptan; Xenazine before Austedo for Huntington chorea; imatinib before dasatinib or nilotinib and imatinib plus dasatinib before Tasigna; preferred Epclusa before specified hepatitis C therapy; generic alternatives before specialty ADHD, seizure, opioid, dermatologic, pulmonary, gastrointestinal, and migraine products.

Product-specific branches: The initial pathways include the listed products from Afrezza through Brivaracetam; Bylvay, Camzyos, Cibinqo, Cimzia, Cosentyx, and Dupixent; Enbumyst, Empaveli, Emgality, Enbrel, Entyvio, Eohilia, Epidiolex, Evrysdi, Fabhalta, Fasenra, Filspari, Furoscix, Gattex, Gemtesa, Glassia, growth hormone, Haegarda, hepatitis C therapies, Hemlibra, Hympavzi, Ibrance, Imcivree, Imiquimod, Increlex, Iqirvo, Kevzara, Kineret, Livmarli, Livtencity, Loargys, Lupkynis, and narcolepsy therapies; and the O-to-X pathways listed in the policy.

Renewal and Continued Coverage

General and medication-specific continuation criteria

Continuation coverage is authorized when the applicable initial criteria remain met and the medication demonstrates the required clinical benefit or objective response.

General renewal: Current indication, age, diagnostic, laboratory, prior-treatment, safety, and concomitant-therapy criteria remain satisfied, and the medication is providing clinical benefit.

Medication-specific response: Alhemo: decreased bleeding. Andembry, Haegarda, Dawnzera, Orladeyo, or Takhzyro: at least 50% reduction in HAE attack number or severity. Camzyos: clinical benefit with LVEF ≥50%. Contrave or orlistat: maintained ≥5% baseline weight loss, current weight, continued lifestyle modification, and BMI ≥18.5 kg/m². Evrysdi: clinically significant motor-function improvement, stabilization, or reduced decline. Gattex: ≥20% reduction in weekly parenteral nutrition or IV-fluid volume. Hemlibra or Qfitlia: decreased bleeds, with Hemlibra also requiring no anti-drug antibodies impairing efficacy. Imcivree: annual review with maintained ≥5% weight or BMI reduction. Lupkynis: clinical benefit such as stabilized or improved GFR or ≥50% proteinuria reduction. Nuplazid: clinically significant psychosis improvement. Qsymia: adult ≥5% weight loss or pediatric ≥1% BMI reduction with the applicable BMI threshold. Pyrukynd: improvement in hemoglobin, hemolysis markers, or transfusion needs. Rezdiffra: no cirrhosis progression plus a specified NASH/MASH or fibrosis benefit. Ruconest or Firazyr: objective acute-attack improvement. Voxzogo: open epiphyses with maintained or increased growth. Wayrilz: stable platelet count ≥50,000/mcL.

Preferred-Drug and Prerequisite Therapy

Requested medication	Required preferred or generic therapy	Failure, intolerance, or exception	Indication-specific sequencing
Afrezza	Novolog	Treatment failure or intolerance to Novolog	Insulin therapy
Aimovig or Ajovy	Two migraine-preventive medications from different classes	Failure or intolerance to the required preventive therapies	Migraine prevention
Chemotherapy-induced nausea/vomiting therapy	Generic 5-HT3 antagonist and preferred NK1 antagonist	Trial and failure of both required classes	CINV prevention
Almotriptan	Two generic triptans: Imitrex, Maxalt, Amerge, or Zomig/ZMT	Trial of two generic triptans	Acute migraine
Austedo for Huntington disease chorea	Generic Xenazine (tetrabenazine)	Failure, contraindication, or intolerance to Xenazine	Huntington disease chorea; tardive dyskinesia does not require this step
Fleqsuvy	Baclofen tablets	Failure or intolerance, unless the member cannot swallow tablets	Spasticity
Beconase AQ	Two listed intranasal steroids: fluticasone, flunisolide, or triamcinolone	Failure or intolerance to two listed steroids	Allergic rhinitis
Belsomra	One of immediate-release zolpidem, eszopiclone, zaleplon, trazodone, or doxepin	Treatment failure with one listed medication	Insomnia; do not combine with another sedative hypnotic
Bonjesta	Generic Diclegis	Failure or intolerance to Diclegis	Nausea and vomiting of pregnancy
Tracleer suspension	Sildenafil or tadalafil, plus ambrisentan or bosentan tablets	Failure of both pulmonary-hypertension treatment components	WHO Group 1 pulmonary arterial hypertension
Bosulif	Imatinib and dasatinib	Failure, contraindication, or intolerance to both	Ph-positive CML
Brivaracetam	Three generic preferred antiseizure alternatives	Failure or intolerance to three alternatives	Seizure disorder or epilepsy
Belbuca	Two long-acting opioids, including a buprenorphine transdermal patch	Failure or intolerance to both; concurrent use of more than one long-acting opioid is not covered	Moderate-to-severe chronic pain requiring around-the-clock opioid therapy
Bronchitol	Nebulized hypertonic saline	Failure, contraindication, or intolerance	Cystic fibrosis pulmonary maintenance therapy
Bylvay	Generic ursodiol; Livmarli for ALGS	Failure, contraindication, or intolerance to required therapy	PFIC: ursodiol; ALGS: ursodiol followed by Livmarli
Bynfezia	Generic octreotide acetate	Treatment failure	Acromegaly, metastatic carcinoid tumor, or VIPoma
Camzyos	Non-vasodilating beta blocker or nondihydropyridine calcium-channel blocker	Failure, contraindication, or intolerance at the maximally tolerated dose	Symptomatic obstructive HCM
Cibinqo	High-potency topical corticosteroid or specified systemic immunomodulator	Treatment failure of one listed therapy	Atopic dermatitis; age-specific requirements apply
Cimzia	Preferred biologics/biosimilars, DMARDs, Orencia, Taltz, or other listed agents	Failure, contraindication, or intolerance as specified	Crohn disease: four agents; RA: DMARD plus three advanced therapies and Orencia; other indications vary
Cladribine	One generic or preferred multiple-sclerosis therapy	Failure or intolerance	Multiple sclerosis
Contraceptives with $0 copayment	At least three generic contraceptives	Failure or intolerance to three generic contraceptives	Pregnancy prevention
Cosentyx	Topical steroids and specified biologic, targeted, conventional, or NSAID therapies	Failure or intolerance to the indication-specific alternatives	Psoriasis, psoriatic arthritis, axial spondyloarthritis, ankylosing spondylitis, hidradenitis suppurativa, or enthesitis-related arthritis
Crexont	Generic Sinemet CR	Treatment failure	Parkinson disease
Ctexli for gallstones	Actigall or ursodiol	Failure or intolerance	Gallstones in a member ineligible for surgery
Dasatinib	Imatinib	Failure, contraindication, or intolerance	Qualifying adult or pediatric Ph-positive CML or ALL pathway
Dawnzera	Haegarda, Takhzyro, Orladeyo, and Andembry	Failure of all four listed HAE prophylaxis products	HAE with qualifying laboratory findings and attack burden
Dayvigo	Three of zolpidem, eszopiclone, zaleplon, trazodone, or doxepin, followed by Belsomra	Failure, contraindication, or intolerance	Insomnia; no concurrent sedative hypnotic
Deferiprone tablets	Generic Jadenu or generic Exjade	Failure or intolerance	Transfusional iron overload due to thalassemia
Deflazacort products	Adequate-dose generic prednisone or prednisolone	Failure, contraindication, or intolerance	Duchenne muscular dystrophy
Desvenlafaxine ER	At least three antidepressants	Failure of at least three agents	Depressive disorder
Dexilant	Four generic proton-pump inhibitors	Failure or intolerance to four listed agents	Acid-related disorder
Diacomit	Two of generic valproic acid, clobazam, or topiramate	Failure, contraindication, or intolerance	Dravet syndrome; use with clobazam
Dichlorphenamide	Lifestyle modification and acetazolamide	Failure, contraindication, or intolerance to acetazolamide	Primary hyperkalemic or hypokalemic periodic paralysis
Diclofenac 2%	Generic oral diclofenac, two other traditional oral NSAIDs, and generic Pennsaid	Trial, failure, or intolerance as specified	Knee osteoarthritis; no concurrent oral NSAID therapy
Diclofenac potassium (Zipsor)	Oral diclofenac and two other preferred oral NSAIDs	Failure of all listed alternatives	Acute pain
Diclofenac sodium 3% gel	Cryotherapy or phototherapy, topical fluorouracil, and generic imiquimod 5%	Failure or intolerance to each prerequisite	Actinic keratosis
Dojolvi	Medium-chain triglycerides at maximally tolerated dose	Trial and failure	Long-chain fatty-acid oxidation disorder
Doryx, Doryx MPC, and doxycycline formulations	Generic doxycycline monohydrate and generic immediate-release doxycycline hyclate	Failure or intolerance to both	Indication-specific doxycycline therapy
Doxepin topical	Two topical steroids plus a preferred topical calcineurin inhibitor; or two OTC topical analgesics plus a preferred topical NSAID	Treatment failure to the applicable sequence	Atopic pruritus, lichen simplex chronicus, or peripheral neuropathic pain
Dupixent	Indication-specific topical, systemic, inhaled, antihistamine, or standard-of-care therapy	Failure or inadequate control after required therapy; contraindication or intolerance where allowed	Atopic dermatitis, asthma, CRSwNP, COPD, EoE, prurigo nodularis, urticaria, bullous pemphigoid, or AFRS
ADHD products in this section	Generic methylphenidate and generic amphetamine product, one long-acting	Failure or intolerance; sprinkle-capable alternative may apply if unable to swallow	ADHD
Ebglyss	Specified high-potency topical or systemic therapy	Treatment failure	Moderate-to-severe atopic dermatitis
Ecoza	Two OTC topical antifungals and two oral generic antifungals	Treatment failure	Tinea pedis
Edarbyclor	Two generic ARBs	Failure or intolerance	Hypertension
Elepsia XR	Three generic or preferred antiseizure alternatives, including generic Keppra	Failure or intolerance	Seizure disorder or epilepsy
Emgality	Two migraine-preventive medications from different classes	Failure of two preventive medications	Migraine prevention
Empaveli for C3G or IC-MPGN	Maximally tolerated ACE inhibitor, ARB, or SGLT2 inhibitor	Required background therapy must be ineffective or otherwise meet the stated pathway	Complement-mediated kidney disease
Enbrel	One DMARD for RA or pJIA; topical steroid for psoriasis	Failure after the applicable minimum trial	RA, pJIA, psoriasis, psoriatic arthritis, or ankylosing spondylitis
Entyvio	Two preferred or listed biologic/targeted therapies; established Entyvio IV	Treatment failure of two alternatives	Ulcerative colitis or Crohn disease
Eohilia	Proton-pump inhibitor or swallowed topical glucocorticoid	Failure, contraindication, or intolerance	Eosinophilic esophagitis
Epidiolex	Generic seizure alternatives; number varies by syndrome	Failure, contraindication, or intolerance to the specified alternatives	Lennox-Gastaut, Dravet, or tuberous-sclerosis-complex seizures
Gelnique	At least two generic overactive-bladder therapies	Failure or intolerance	Overactive bladder
Gemtesa	Two preferred overactive-bladder therapies	Failure or intolerance to both	Overactive bladder
Ravicti	Buphenyl (sodium phenylbutyrate)	Treatment failure	Urea-cycle disorder with dietary management
Grastek	One intranasal corticosteroid and one oral or intranasal antihistamine	Trial of one agent from each class	Grass-pollen allergic rhinitis
Non-preferred growth hormone products	All preferred products: Genotropin and Norditropin	Failure of all preferred products	Adult or pediatric growth hormone indications
Sofosbuvir-containing therapy or Harvoni oral pellets	Preferred Epclusa	Failure of Epclusa in adults where specified	Qualifying chronic hepatitis C
Hetlioz LQ for Smith-Magenis syndrome	OTC melatonin and acebutolol	Failure, contraindication, or intolerance	Smith-Magenis syndrome with nighttime sleep disturbance
Hetlioz LQ for restless legs syndrome	Two of pramipexole, ropinirole, gabapentin, or pregabalin	Failure, contraindication, or intolerance	Restless legs syndrome
Hetlioz LQ for post-herpetic neuralgia	Generic gabapentin; generic tricyclic antidepressant if under 65	Failure, contraindication, or intolerance	Post-herpetic neuralgia
Hydrocodone bitartrate, hydrocodone, and Exalgo	Three generic long-acting opioids	Failure or intolerance; concurrent use of more than one long-acting opioid is not covered	Moderate-to-severe chronic pain
Hympavzi for hemophilia A	Hemlibra	Failure or intolerance	Hemophilia A without factor VIII inhibitors
Ibrance	Kisqali and Verzenio	Failure, contraindication, or intolerance to both	HR-positive breast cancer primary pathway
Ibsrela	Lactulose or polyethylene glycol, and Linzess	Failure or intolerance to both steps	Constipation
Imiquimod for actinic keratosis	Cryotherapy or phototherapy, topical fluorouracil, and generic imiquimod 5%	Failure or intolerance to each prerequisite	Actinic keratosis; wart pathway has no listed step
Non-preferred subcutaneous immunoglobulins	Gammagard and Hizentra	Failure or intolerance to all preferred products	Diagnosis requiring subcutaneous immunoglobulin
Iyuzeh	One generic or preferred ophthalmic prostaglandin analog	Trial of one product	Glaucoma
Jatenzo	One generic or preferred testosterone product, followed by Kyzatrex	Failure, contraindication, or intolerance	Male hypogonadism
Jornay PM	One generic stimulant	Failure or intolerance	ADHD
Karbinal ER	Generic carbinoxamine and two other generic antihistamines	Treatment failure	Allergic condition
Kevzara or Kineret specified rheumatology pathways	One DMARD, three biologic/targeted therapies, and Orencia	Failure or intolerance; other Kineret pathways use steroids, NSAIDs, or colchicine	RA and selected inflammatory conditions
L-glutamine	Hydroxyurea and OTC L-glutamine	Failure, contraindication, or intolerance; hydroxyurea step is generally at least six months	Sickle cell disease
Kyzatrex before Jatenzo	Kyzatrex	Failure or intolerance to the required testosterone pathway	Male hypogonadism
Livmarli	Generic ursodiol; Bylvay additionally for PFIC	Failure, contraindication, or intolerance	ALGS: ursodiol; PFIC: ursodiol followed by Bylvay
Livtencity	Ganciclovir, valganciclovir, cidofovir, or foscarnet	Treatment failure	Post-transplant CMV infection or disease
Narcolepsy therapies	Wakix; generic or preferred stimulant; adult pathways also use modafinil/armodafinil and Sunosi	Failure, contraindication, or intolerance as applicable by age and indication	Cataplexy: Wakix; excessive daytime sleepiness: stimulant plus Wakix, then adult-specific agents
Lupkynis	Cyclophosphamide plus glucocorticoids or mycophenolate mofetil plus glucocorticoids; Benlysta and Gazyva	Failure, contraindication, or intolerance	Active lupus nephritis
Lyvispah	Baclofen tablets	Failure, unless unable to swallow tablets	Spasticity
Nemluvio	Indication-specific conventional therapy; Dupixent additionally for prurigo nodularis	Failure, contraindication, or intolerance	Atopic dermatitis or prurigo nodularis
Nexletol or Nexlizet	High-intensity statin, two generic statins for intolerance, or one statin if rhabdomyolysis occurred	The applicable statin-intolerance or rhabdomyolysis pathway may substitute for maximum-dose statin trial	Cardiovascular risk, hypercholesterolemia, or HeFH
Nilotinib	Imatinib	Failure, contraindication, or intolerance	Ph-positive CML
Noctiva	One generic OAB medication and generic oral desmopressin after lifestyle changes	Failure or intolerance to OAB medication; trial of desmopressin	Nocturnal polyuria
Nourianz	Dopamine agonist or COMT inhibitor added to levodopa	Failure or intolerance	Parkinson disease with intermittent off episodes
Nurtec ODT for acute migraine	Two generic triptans	Failure or contraindication	Acute migraine
Nurtec ODT for migraine prevention	Two medications from different preventive classes	Failure or intolerance to both	Migraine prevention; no concurrent CGRP antagonist
Nyvepria	Neulasta and Ziextenzo	Failure or intolerance to both	Pegfilgrastim support
Odactra or Ragwitek	One intranasal corticosteroid and one oral or intranasal antihistamine	Trial of one agent from each class	Allergic rhinitis; product-specific allergen applies
Ohtuvayre	Dual LABA/LAMA therapy	Failure of dual therapy	COPD
Olpruva or Pheburane	Buphenyl (sodium phenylbutyrate)	Treatment failure	Urea-cycle disorder with dietary management
Olumiant or Orencia SC	DMARD and specified advanced biologic or targeted therapies	Failure or intolerance; required number varies by indication and age	RA, pJIA, psoriatic arthritis, psoriasis, or severe alopecia areata
Omnaris	Two of generic fluticasone, generic flunisolide, or OTC Nasacort	Failure or intolerance	Allergic rhinitis
Onapgo	Levodopa plus at least one adjunctive Parkinson therapy	Inadequate control despite current regimen	Advanced Parkinson disease motor fluctuations
Onzetra Xsail	Generic sumatriptan nasal spray plus another generic triptan; adolescents may use generic rizatriptan	Failure or intolerance	Acute migraine
Opsynvi	Sildenafil or tadalafil plus ambrisentan and bosentan	Failure, intolerance, or contraindication; exception if stable on individual components	WHO Group I PAH, functional class II–III
Oracea	Generic doxycycline monohydrate and generic immediate-release doxycycline hyclate	Failure or intolerance to both	Rosacea
Orgovyx	Firmagon	Failure, contraindication, or intolerance	Advanced prostate cancer
Oriahnn or Orilissa	Two hormone-related therapies; Oriahnn also requires Myfembree	Trial of required therapies	Fibroid-related bleeding or endometriosis pain
Otezla or Otezla XR	One topical steroid for psoriasis or Behcet-related oral ulcers	Treatment failure; no step listed for psoriatic arthritis alone	Psoriatic arthritis, psoriasis, or Behcet oral ulcers
Otrexup	Oral methotrexate followed by injectable methotrexate	Treatment failure of both formulations	RA, pJIA, or psoriasis
Oxcarbazepine extended-release	At least three generic alternatives, including generic oxcarbazepine	Failure or intolerance	Epilepsy with seizures
Opana ER	Three generic long-acting opioids	Failure or intolerance; concurrent use of more than one long-acting opioid is not covered	Moderate-to-severe chronic pain
Ozempic	One generic or preferred type 2 diabetes medication when applicable	Trial may be bypassed when coverage is requested directly for type 2 diabetes treatment	Type 2 diabetes; no concurrent GLP-1 agonist-containing product
Palsonify	One of generic octreotide, Sandostatin LAR, Somatuline Depot, Mycapssa, or Signifor LAR	Failure of at least one listed therapy	Acromegaly
Pancreatic enzyme products	Creon and Zenpep	Treatment failure of both	Pancreatic enzyme insufficiency
Qsymia	Lifestyle modification program	Physician attestation required; pediatric BMI pathway differs from adult BMI pathway	Adult obesity/overweight or pediatric obesity
Phenoxybenzamine	Preferred alpha1 blocker plus calcium-channel blocker; non-preoperative pathway requires two alpha1 blockers	Failure or intolerance	Pheochromocytoma-related hypertension or sweating
Pitavastatin	At least two generic statins	Failure or intolerance	Hyperlipidemia
Prucalopride	Lactulose or polyethylene glycol and Linzess	Failure or intolerance to both steps	Chronic constipation
Qnasl	Two intranasal steroids: fluticasone, flunisolide, or OTC Nasacort	Failure or intolerance	Allergic rhinitis
Qelbree or Quillichew ER	Generic or preferred ADHD products, including methylphenidate and amphetamine products	Failure or intolerance; formulation exception may apply if unable to swallow	ADHD
Qulipta	Two medications from different migraine-preventive classes	Failure or intolerance; no concurrent CGRP antagonist for prevention	Migraine prevention
Quviviq	Three listed sedative-hypnotics followed by Belsomra	Failure, contraindication, or intolerance	Insomnia
Ragwitek	One intranasal corticosteroid and one oral or intranasal antihistamine	Trial of one agent from each class	Short-ragweed allergic rhinitis
Rasuvo	Injectable methotrexate; oral methotrexate may also be required	Treatment failure or intolerance	RA, pJIA, or psoriasis
Rebif	Two generic or preferred multiple-sclerosis medications	Failure or intolerance	Multiple sclerosis
Recorlev	Ketoconazole, mitotane, or cabergoline	Failure, contraindication, or intolerance	Endogenous hypercortisolemia in Cushing syndrome
Repatha	One high-intensity statin; two generic statins for intolerance; or one statin after rhabdomyolysis	Statin intolerance or rhabdomyolysis pathway may apply; no concurrent PCSK9 inhibitor	Primary hyperlipidemia, cardiovascular-risk reduction, or familial hypercholesterolemia
Rexulti or Secuado	Two preferred second-generation antipsychotics	Failure, contraindication, or intolerance	Schizophrenia, adjunctive MDD, or related psychiatric indication
Rinvoq or Rinvoq LQ	DMARD and/or TNF inhibitor, depending on indication	Failure, contraindication, or intolerance; minimum three months where specified	RA, PsA, pJIA, AD, UC, Crohn disease, AS, nr-axSpA, or GCA
Rivfloza	High-dose vitamin B6	Failure, contraindication, or intolerance after at least three months; no concurrent Oxlumo	Primary hyperoxaluria type 1
Rolvedon	Neulasta and Ziextenzo	Failure or intolerance to both	Pegfilgrastim support
Ruconest	Generic Firazyr	Treatment failure; no concurrent acute HAE product	Acute HAE attacks
Lennox-Gastaut seizure therapy	At least three generic seizure alternatives	Failure, contraindication, or intolerance	Lennox-Gastaut syndrome
Rytary	Generic Sinemet CR	Treatment failure	Parkinson disease
Sancuso	Generic ondansetron/ODT and generic granisetron	Treatment failure	Chemotherapy- or radiation-related nausea/vomiting
Sephience	Generic sapropterin	Failure or intolerance	Sepiapterin-responsive PKU/HPA
Sotyktu	One topical steroid and two listed systemic or biologic alternatives	Failure or intolerance to the pathway-specific agents	Adult psoriasis or psoriatic arthritis
Sovaldi	Preferred Epclusa	Failure of Epclusa; pediatric genotype 2/3 pathway uses ribavirin	Qualifying chronic hepatitis C
Spevigo	Acitretin, methotrexate, cyclosporine, or infliximab	Continued GPP flares during or after therapy; contraindication or intolerance may apply	Prevention of GPP flares
Stimufend	Neulasta and Ziextenzo	Failure or intolerance to both	Granulocyte colony-stimulating-factor support
Sumatriptan/naproxen combination	Generic sumatriptan plus naproxen and a second generic triptan; ages 12–17 may use generic Maxalt	Failure or intolerance	Acute migraine
Tadalafil suspension	Generic sildenafil suspension	Failure, intolerance, or contraindication; inability to swallow tablets required	WHO Group 1 PAH
Taltz	Indication-specific topical steroid and biologic/targeted therapies	Failure, contraindication, or intolerance as specified	Psoriasis, PsA, nr-axSpA, or ankylosing spondylitis
Tapentadol immediate-release	Three generic immediate-release opioids	Failure or intolerance	Acute pain
Nucynta ER	Three generic long-acting opioids and Xtampza ER where applicable	Failure or intolerance; age-specific neuropathic-pain steps may apply	Chronic pain or diabetic peripheral neuropathy; no concurrent long-acting opioid
Tarpeyo	Maximally tolerated ACE inhibitor or ARB, generic corticosteroid, and SGLT2 inhibitor	Contraindication or intolerance may substitute where specified; ACEi/ARB may be omitted if contraindicated	Primary IgA nephropathy at risk of progression
Tasigna	Imatinib and dasatinib	Failure, contraindication, or intolerance	Ph-positive CML
Tasimelteon	OTC melatonin and Rozerem; SMS also requires acebutolol	Failure, contraindication, or intolerance	Non-24-hour sleep-wake disorder or Smith-Magenis syndrome
Teriparatide, Forteo, or Tymlos	Very high risk: zoledronate, or preferred denosumab if zoledronate is contraindicated; high risk: oral/IV bisphosphonate and preferred denosumab	Failure, contraindication, or intolerance according to risk pathway	Osteoporosis with high- or very-high-fracture risk
Tezspire	Daily oral corticosteroid or high-dose inhaled corticosteroid plus LABA, leukotriene modifier, or LAMA	Inadequate control after at least three months; required standard-of-care therapy continues	Eosinophilic, allergic, oral-corticosteroid-dependent, or severe asthma; CRSwNP pathway
Teglutik or Tiglutik	Generic riluzole tablets	Difficulty swallowing tablets may substitute for the trial	ALS
Tobi Podhaler	Generic Tobi tobramycin inhalation nebulization solution	Failure	Cystic fibrosis with Pseudomonas aeruginosa
Tofacitinib formulations	Formulation-specific DMARD and TNF-inhibitor therapy	Failure or intolerance; DMARD trial generally at least three months where stated	RA, PsA, UC, pJIA, or ankylosing spondylitis
Eprontia, topiramate ER, or Trokendi XR	At least three generic alternatives, including generic topiramate where specified	Failure or intolerance	Epilepsy, Lennox-Gastaut syndrome, or migraine prevention
Tremfya for psoriasis	One topical steroid	Failure	Psoriasis
Trulicity	One generic or preferred type 2 diabetes medication when coverage is not requested directly for diabetes	Trial may be bypassed for direct type 2 diabetes treatment	Type 2 diabetes; no concurrent GLP-1 agonist-containing product
Tyenne	Indication-specific DMARD, glucocorticoid, NSAID, mycophenolate mofetil, or cyclophosphamide therapy	Failure, intolerance, contraindication, or lack of candidacy as specified	RA, pJIA, Still disease, GCA, or SSc-ILD
Ubrelvy	Two generic triptans	Failure or contraindication	Acute migraine in adults
Uptravi or Ventavis	Sildenafil or tadalafil plus ambrisentan or bosentan	Treatment failure of required pulmonary-hypertension components	WHO Group 1 PAH; PH-ILD pathway may not require the same steps
Varubi	All generic 5-HT3 antagonists and a preferred NK1 antagonist	Failure of all required antiemetic classes	Chemotherapy-induced nausea/vomiting prevention
Vernal keratoconjunctivitis therapy	Dual-acting topical antihistamine/mast-cell stabilizer, ophthalmic corticosteroid, and generic Restasis; compromised-cornea pathway requires Restasis	Failure or intolerance to required topical therapies	Vernal keratoconjunctivitis
Vesicare LS	Two anticholinergic drugs	Treatment failure; formulation exception may apply if unable to swallow and solution has failed	Neurogenic detrusor overactivity
Vigabatrin powder	Three generic seizure alternatives and Sabril powder for epilepsy pathway	Failure, contraindication, or intolerance	Infantile spasms or adjunctive epilepsy treatment
Viokace	Creon and Zenpep	Treatment failure of both	Exocrine pancreatic insufficiency
Voquezna-like therapy	Generic first-line H. pylori regimen or three generic/OTC PPIs	Trial and failure, contraindication, or intolerance as applicable	H. pylori, erosive esophagitis, or non-erosive GERD
Vosevi	Prior NS5A regimen; applicable sofosbuvir regimen; preferred Epclusa	Prior regimen failure and treatment-experience documentation required	Treatment-experienced chronic hepatitis C
Voydeya	Empaveli and Fabhalta	Failure, contraindication, or intolerance; must be added to Soliris or Ultomiris	PNH with clinically significant extravascular hemolysis
Voyxact	Maximally tolerated ACE inhibitor or ARB, SGLT2 inhibitor, Tarpeyo, and preferred endothelin receptor antagonist	Failure, contraindication, or intolerance; exceptions apply	Primary IgA nephropathy at risk of progression
Vtama	Any generic topical therapy	Treatment failure	Dermatologic indication
Vyvgart Hytrulo for MG	One listed standard-of-care immunosuppressant for at least 12 weeks	Ineffective treatment; all options may be excepted if contraindicated or not tolerated	AChR-antibody-positive myasthenia gravis
Vyvgart Hytrulo for CIDP	Generic corticosteroids or immunoglobulin therapy	Failure, contraindication, or intolerance	CIDP
Vyzulta	Three generic preferred prostaglandin medications	Failure, contraindication, or intolerance	Elevated intraocular pressure/glaucoma
Wakix for narcolepsy with cataplexy	Wakix when age appropriate	Failure, contraindication, or intolerance	Narcolepsy with cataplexy
Wakix for narcolepsy with excessive daytime sleepiness	Generic or preferred stimulant plus Wakix; adults also modafinil or armodafinil and Sunosi	Failure, contraindication, or intolerance	Narcolepsy with excessive daytime sleepiness
Wayrilz	Generic eltrombopag	Failure or non-candidacy for corticosteroids, immunoglobulins, or splenectomy; current severe thrombocytopenia or bleeding	Chronic immune thrombocytopenia
Winlevi	One oral acne agent and three topical acne agents	Failure, contraindication, or intolerance	Acne
Winrevair	Generic sildenafil or tadalafil and generic or preferred endothelin-receptor antagonist	Failure, intolerance, or contraindication	WHO Group 1 PAH
Xcopri	At least three generic seizure-treatment alternatives	Failure or intolerance	Epilepsy with seizures
Xelpros	Two preferred glaucoma medications, such as Xalatan, Lumigan, or Travatan Z	Treatment failure	Elevated intraocular pressure
Xepi	Generic Bactroban	Trial required	Impetigo
550-mg product for IBS-D	Tricyclic antidepressant	Failure, contraindication, or intolerance	IBS-D
550-mg product for SIBO	Two generic antibiotics	Failure	SIBO confirmed by breath test
550-mg product for IMO	Neomycin	Use unless contraindicated	IMO confirmed by breath test
550-mg product for hepatic encephalopathy	Lactulose	Failure, contraindication, or intolerance	Hepatic encephalopathy
Xolair for allergic asthma	Daily oral or high-dose inhaled corticosteroid plus appropriate controller	Inadequate control after at least three months	Uncontrolled moderate-to-severe allergic asthma
Xolair for chronic spontaneous urticaria	Maximal-dose second-generation antihistamine plus one additional listed therapy	Failure after the required therapy duration	Chronic spontaneous urticaria
Xyosted	Generic Depo-testosterone or generic Delatestryl	Failure, contraindication, or intolerance	Male hypogonadism
Xywav for narcolepsy with cataplexy	Wakix when age appropriate	Failure, contraindication, or intolerance	Age ≥7; narcolepsy with cataplexy
Xywav for narcolepsy with excessive daytime sleepiness	Generic or preferred stimulant and Wakix; adults also modafinil or armodafinil and Sunosi	Failure, contraindication, or intolerance	Narcolepsy with excessive daytime sleepiness
Xywav for idiopathic hypersomnia	No specific prior therapy listed in the rendered pathway	Age ≥18 and qualifying diagnosis required	Idiopathic hypersomnia

Step Therapy

Complete step therapy before submission

Complete the required preferred-drug trial before requesting a nonpreferred medication. Document treatment failure, contraindication, or intolerance when the applicable criterion allows it, and submit the sequence and outcome with the authorization request.

Confirm the required alternative and order of therapy for the specific drug and indication.
Record the trial duration, treatment outcome, contraindication, or intolerance.
Examples include preferred Epclusa before specified hepatitis C therapies, generic Sinemet CR before Crexont or Rytary, and two generic triptans before Ubrelvy.

Prior Authorization and Submission Requirements

Prior Authorization

Secure authorization and support the request

Obtain prior authorization before prescribing a medication subject to this policy and submit documentation supporting medical necessity. Coverage may be denied when required documentation, step therapy, clinical criteria, or plan benefits are not satisfied.

Submit the diagnosis, age or weight, disease severity, laboratory or diagnostic confirmation, prior-treatment history, and applicable specialist information.
Confirm that required alternatives have been tried and failed, or that contraindication or intolerance is documented where permitted.
Verify the member’s prescription drug benefit; medications excluded from the plan may be denied or may fall under the medical benefit.

Prior Authorization

Match the request to medication-specific criteria

For each requested medication, submit the drug-specific indication and all applicable age, diagnostic, laboratory, prior-treatment, dosing, safety, specialist, and renewal requirements. The policy includes medication-specific criteria ranging from Accrufer after two over-the-counter iron-product failures to specialty therapies requiring genetic confirmation, specialist care, or multiple preferred-drug failures.

Approval Durations and Quantity Restrictions

Quantity limits and approval periods

Erectile dysfunction and infertility productsCaverject, Muse, sildenafil (Viagra), Staxyn, Stendra, and vardenafil (Levitra) may be subject to plan-specific quantity limits; infertility products remain subject to the member’s fertility benefit.

Gallstone therapyCoverage for Chenodal and Ctexli used for gallstones is limited to 24 months.

Eltrombopag (Promacta) maximum dosesMaximum daily doses are 75 mg for chronic ITP, 100 mg for thrombocytopenia associated with chronic hepatitis C, and 150 mg for severe aplastic anemia.

Short approval periodsDrug-specific initial approval periods include 60 days, 90 days, 3 months, 6 months, 12 weeks, and 1 year.

Imcivree approval periodsInitial approval is 4 months for POMC, PCSK1, or LEPR deficiency and 1 year for Bardet-Biedl syndrome.

Longer approval limits

Administration and Dispensing Location

Billing Rule

Verify site-of-care requirements

Confirm the required administration setting before dispensing. Some medications excluded from the prescription benefit may be covered under the medical benefit when administered in a physician’s office or another approved site of care; other therapies require outpatient stability, home administration, specialist dispensing, or hospital initiation.

Hemophilia products including Alhemo, Hemlibra, Hympavzi, and Qfitlia must be prescribed and dispensed through a specialist or treatment center associated with a hemophilia treatment center.
Samsca must be initiated or re-initiated in a hospital.
Winrevair is self-administered unless the member is clinically unable to do so; applicable immunoglobulin criteria require subcutaneous administration.
Xolair prefilled-syringe self-administration requires the first three doses under health-care-provider guidance.

Clinical Thresholds and Eligibility Values

Age, laboratory, weight, severity, response, and clinical thresholds

Age thresholdsExamples include Accrufer ≥10 years, Adbry ≥12 years, Alyftrek ≥6 years, Alhemo ≥12 years, Loargys ≥2 years, Livtencity ≥12 years, Lupkynis ≥18 years, Spevigo ≥12 years, Tascenso ODT ≥10 years, and adult pathways generally ≥18 years.

Hemophilia laboratory thresholdsHigh factor VIII or IX inhibitor titer is >5 BU/mL; severe hemophilia has factor VIII or IX levels <1%; moderate hemophilia has levels of 1%–5%.

Hereditary angioedema laboratory thresholdsQualifying HAE findings include C4 below the laboratory normal range, stated as 16–58 mg/dL, and C1 inhibitor antigenic or functional level below normal, with normal function stated as ≥41%.

Platelet and hematologic thresholdsChronic or persistent ITP requires platelets <100,000/mcL for at least 3 months; qualifying current counts include <20,000/mcL or <30,000/mcL with active bleeding. Eltrombopag also uses hepatitis C platelets <75,000/mcL and severe aplastic anemia platelets ≤30,000/mcL.

Cardiac thresholdsCamzyos initial LVEF must be >55% and renewal LVEF ≥50%, with LVOT peak gradient ≥50 mmHg. Myqorzo requires LVEF ≥55% and LVOT gradient ≥50 mmHg; Verquvo requires LVEF <45%.

Policy Terms and Abbreviations

Definitions and abbreviations

Prior authorizationA utilization-management process requiring the physician to submit documentation supporting the need for a medication before MESSA will cover it.

Step therapyA utilization-management process requiring previous treatment with one or more preferred drugs before coverage of the requested medication is approved.

NCNot covered; the member may be responsible for the full cost of the medication.

DMARD and targeted DMARDDMARD means disease-modifying antirheumatic drug; targeted DMARD means targeted disease-modifying antirheumatic drug.

HAE and related laboratory termsHAE means hereditary angioedema. Qualifying laboratory confirmation uses C4 and C1 esterase inhibitor values below the laboratory reference range.

Cardiac and pulmonary abbreviationsLVEF means left ventricular ejection fraction; LVOT gradient means left ventricular outflow tract peak gradient; PAH means pulmonary arterial hypertension, classified as WHO Group 1; PH-ILD means pulmonary hypertension associated with interstitial lung disease.

Policy Background

MESSA uses prior authorization to confirm that selected medications are prescribed consistently with FDA-approved safe-prescribing requirements and that the request is supported by documented medical necessity. The review may require diagnosis and severity information, laboratory or genetic confirmation, prior-treatment history, and evidence that medication-specific criteria are satisfied before coverage is approved.

Step therapy directs members to try preferred or lower-cost alternatives before a nonpreferred medication is covered. The policy applies this review across common and specialty conditions, including dermatologic disease, pulmonary hypertension, hemophilia, cystic fibrosis, hereditary angioedema, rare metabolic disease, hematologic disease, neurologic disease, and psychiatric conditions.

Preferred Biosimilar and Biologic Options