CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Branded bisphosphonate coverage and step therapy

Defines initial step therapy and post-step-therapy prior authorization (PA) requirements for branded bisphosphonate medications administered under a CVS Caremark prescription benefit for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBranded bisphosphonate coverage and step therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf the member has not filled at least a 28-day supply of a generic bisphosphonate within the past 365 days under the CVS Caremark benefit, submit a prior authorization for evaluation against the post-step-therapy criteria and include supporting clinical documentation as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

28 daysminimum generic bisphosphonate fill to satisfy initial step

365 dayslookback period for prior generic bisphosphonate fill

1minimum number of generic bisphosphonates tried for PA criteria

Branded Bisphosphonate Coverage Requirements

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Post Step Therapy Prior Authorization (Medically Necessary Conditions)

A branded bisphosphonate will be covered with PA when ANY of the following are met:

ANY of the following

Patient has experienced an inadequate treatment response after a sufficient trial of at least one generic bisphosphonate drugminimum number of generic bisphosphonates tried >= 1
Inadequate response determined on most recent DEXA scan
Patient has a documented contraindication or a potential drug interaction that would prohibit a trial with at least one generic bisphosphonate drugminimum number of generic bisphosphonates tried >= 1
Patient has experienced an intolerance to at least one generic bisphosphonate drugminimum number of generic bisphosphonates tried >= 1

What Providers Must Do

Prior Authorization

Prior authorization required when initial step therapy not met

If the member has not filled at least a 28‑day supply of a generic bisphosphonate within the past 365 days under the CVS Caremark benefit, the branded claim will reject and the provider must submit a prior authorization (PA) for evaluation against the post‑step‑therapy criteria.

Documentation Required

Support PA with clinical evidence

For PA requests based on inadequate response, include documentation from the most recent DEXA scan; for requests based on contraindication, potential drug interaction, or intolerance, include clinical notes or test results that document why a generic bisphosphonate cannot be used.

Clinical and Administrative Context

This policy implements CVS Caremark utilization management criteria for branded bisphosphonate medications. Under the Initial Step Therapy requirement, a branded bisphosphonate will be paid under the prescription benefit only if the member has filled at least a 28‑day supply of at least one generic bisphosphonate within the past 365 days. If that initial step therapy requirement is not met, the claim will reject and a prior authorization (PA) is required for further review.

When the initial step therapy is not met, branded bisphosphonate coverage may still be approved through a Post Step Therapy Prior Authorization. Approval is granted when ANY of the following are documented: an inadequate treatment response after a sufficient trial of at least one generic bisphosphonate (inadequacy determined by the most recent DEXA scan), a documented contraindication or potential drug interaction that prevents a trial of a generic bisphosphonate, or an intolerance to at least one generic bisphosphonate. Clinical documentation (for example, recent DEXA results or clinical notes) should be provided to support the PA request.

Defined Terms

Initial Step TherapyRequirement that the member fill a minimum 28-day supply of a generic bisphosphonate within the prior 365 days before a branded bisphosphonate will be paid under the prescription benefit.

Post Step Therapy Prior AuthorizationAuthorization process to approve branded bisphosphonate when step therapy is not met, based on inadequate response, contraindication/interactions, or intolerance to generic bisphosphonates.