CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Step Therapy Criteria

Partial extract of a Step Therapy Criteria mapping: many numbered group placeholders and drug-name slots are empty; fragment includes several explicit prior‑trial (step) requirements for selected agents (aripiprazole ODT, risperidone ODT, entecavir, lamotrigine, bisphosphonates, levalbuterol, olanzapine ODT, esomeprazole magnesium, tolterodine ER).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStep Therapy Criteria

Policy CodePolicy N/A

Change TypeClarifications / extracted step requirements

Effective Date

Next Review Date

Key ActionDocument prior trials: ensure records show the member tried the specified generic alternative(s) (typically ≥30‑day supply within prior 180 days) before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Explicit step therapy criterion for aripiprazole ODT: generic aripiprazole immediate‑release tablet must be tried (≥30‑day supply in prior 180 days).

Prior trial required for entecavir: generic entecavir tablets must have been tried (≥30‑day supply in prior 180 days).

Bisphosphonate group: prior trial of alendronate, ibandronate, or risedronate is required before coverage.

Lamotrigine products: require prior trial of generic immediate‑release or chewable/dispersible lamotrigine (≥30‑day supply).

Levalbuterol: require prior trial of albuterol HFA or Ventolin HFA (≥30‑day supply in prior 180 days).

Olanzapine ODT: prior trial of generic olanzapine immediate‑release tablet required before coverage.

Esomeprazole magnesium: require trial of two specified generics (examples include omeprazole, pantoprazole, lansoprazole) with ≥30‑day supplies in prior 180 days.

Risperidone ODT: coverage requires prior trial of generic risperidone immediate‑release tablet (≥30‑day supply in prior 180 days).

Tolterodine tartrate ER: prior trial of one listed generic urinary antispasmodic (≥30‑day supply in prior 180 days) required.

No material change: large portion of the fragment contains numbered Step Therapy Group and Drug Names placeholders with minimal substantive criteria.

≈445Placeholder groups listed

multipleExplicit step rules found

1Groups with non-empty mapping

≈10Named drug mentions

NoMaterial clinical changes

What is changing (summary)

Step therapy requirements and provider actions (explicit rules found)

Step Therapy Criteria - explicit rule present

Step Therapy Criteria - explicit rules and extracted fragmentary requirements. Each group below preserves the original logical structure and threshold (30-day supply in prior 180 days) where specified.

ARIPIPRAZOLE ODT - Step Therapy Criteria (explicit)

Prior trial of generic aripiprazole immediate-release (IR) tablet>= 30-day supply in prior 180 days
AND logic preserved from source: generic aripiprazole IR tablet trial required before aripiprazole ODT coverage.

RISPERIDONE ODT - Step Therapy Criteria

Prior trial of generic risperidone immediate-release (IR) tablet

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStep Therapy Criteria

Policy CodePolicy N/A

Change TypeClarifications / extracted step requirements

Effective Date

Next Review Date

Key ActionDocument prior trials: ensure records show the member tried the specified generic alternative(s) (typically ≥30‑day supply within prior 180 days) before requesting coverage.

SourceLink

On This Page

Step Therapy group mappings and drug-name index (fragment)

Step Therapy Group identifiers present (fragment)mixed

1	RISPERIDONE ODT
2-445	placeholder entries (many blank)
Step Therapy Group 1	ARIPIPRAZOLE ODT (fragment shows Group 1 = ARIPIPRAZOLE ODT)
Step Therapy Group 2	placeholder
Step Therapy Group 3	placeholder
Step Therapy Group 4	placeholder
Step Therapy Group 5	placeholder
Step Therapy Group 6	placeholder
Step Therapy Group 7	placeholder
Step Therapy Group 8	placeholder

1–10 of 410

1/41

Drug names referenced in fragmentmixed

ESOMEPRAZOLE MAGNESIUM	Drug name referenced in fragment (no NDC provided)
OMEPRAZOLE	Drug name referenced in fragment (no NDC provided)
RISPERIDONE ODT	Drug name referenced in fragment (also listed as code 1)
LAMOTRIGINE	Drug name referenced in fragment (where present)
ARIPIPRAZOLE ODT	Drug name referenced in fragment (Step Therapy Group 1 = ARIPIPRAZOLE ODT)

This section is a partial extract of the master Step Therapy Group-to-drug mapping table. Many group identifiers in the 2-445 range are placeholders in this fragment and contain no mapped drug names here. For authoritative, complete mappings and any codes not populated in this fragment (including full listings for codes 210-445 and all Step Therapy Groups), consult the complete policy master file — do not infer or invent mappings from this partial extract.