CurrentNeighborhood Health Plan of Rhode IslandPolicy 367-D, 401-D, 377-D 11-2022

Branded Bisphosphonates — Post Step Therapy Prior Authorization

Defines post-step-therapy prior authorization requirements for coverage of branded bisphosphonate medications for members whose prescription benefits are administered by CVS Caremark; affects prescribers and pharmacy prior authorization reviewers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBranded Bisphosphonates — Post Step Therapy Prior Authorization

Policy CodePolicy 367-D, 401-D, 377-D 11-2022

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionObtain and submit clinical evidence (e.g., most recent DEXA) showing trial failure, contraindication/interaction, or intolerance to at least one generic bisphosphonate (>=28 days within prior 365 days) when requesting prior authorization for a branded bisphosphonate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365Lookback (days)

>=28Minimum prior fill

1Generics required

Coverage Criteria — Branded Bisphosphonates

Coverage criteria (post-step-therapy PA)

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Branded bisphosphonate coverage criteria

Inadequate response after trial of generic bisphosphonate: The patient has experienced an inadequate treatment response as determined by the most recent DEXA scan after a sufficient trial of at least one generic bisphosphonate drug.
Documented contraindication or potential drug interaction: The patient has a documented contraindication or a potential drug interaction that would prohibit a trial with at least one generic bisphosphonate drug.
Intolerance to generic bisphosphonate: The patient has experienced an intolerance to at least one generic bisphosphonate drug.

Threshold: >= 1 generic bisphosphonate tried/contraindicated/intolerant>=1 generic bisphosphonate tried/contraindicated/intolerant

No explicit exclusions are listed in this policy beyond the requirement that the request meet one of the specified coverage criteria for branded bisphosphonate coverage. Coverage of a branded bisphosphonate is contingent on satisfying one of the clinical conditions described in the policy (inadequate response, documented contraindication/interaction, or intolerance to a generic bisphosphonate) and submission of the required clinical documentation for prior authorization review.

Requests for a branded bisphosphonate that do not document either an inadequate treatment response (with supporting evidence such as the most recent DEXA), a documented contraindication or potential drug interaction precluding trial of a generic bisphosphonate, or a documented intolerance to at least one generic bisphosphonate will not meet the coverage criteria and are subject to denial. The policy requires evidence that the patient has tried or is unable to try a generic option before branded coverage will be considered under the post-step-therapy prior authorization process.

Coding Rules & Lookback

inv-04: Minimum prior fill duration

Minimum prior fill duration>= 28 days

PurposeDefines the minimum continuous supply of a generic bisphosphonate that must have been filled to trigger step-therapy recognition

ApplicationMust be documented as a filled prescription under the member's CVS Caremark benefit to count toward the requirement

inv-05: Lookback period for prior fill

Lookback period for prior fill365 days

Window descriptionPrior 365 days from date of request to identify qualifying generic bisphosphonate fills

Relation to PA triggerA >=28-day generic bisphosphonate fill within this 365-day window will prompt a PA requirement for branded agents

Provider Actions & Prior Authorization

Prior Authorization

Post-step-therapy prior authorization required

Post-step-therapy prior authorization is required for branded bisphosphonates when the patient has failed, is intolerant of, or has a contraindication to a generic bisphosphonate. Submit supporting clinical documentation with the PA request.

Required: documentation of inadequate treatment response (e.g., most recent DEXA scan showing failure on generic bisphosphonate)
Acceptable: documented contraindication or drug interaction preventing generic bisphosphonate use
Acceptable: documented intolerance to at least one generic bisphosphonate

Step Therapy

Step therapy requirement

Step therapy is triggered when there is evidence the patient filled at least a 28-day supply of a generic bisphosphonate in the prior 365 days under a CVS Caremark-administered prescription benefit. If such a fill is found, the branded bisphosphonate request will require PA and is subject to step therapy rules.

Trigger: ≥28-day supply fill of a generic bisphosphonate within the past 365 days under CVS Caremark
Operational note: PA message will indicate step therapy applied and may require documentation outlined above

Denial Risk

Denial risk without documentation

If the required documentation demonstrating failure, intolerance, or contraindication to a generic bisphosphonate is not provided, the PA request may be denied.

PA may be denied without required supporting clinical documentation
Ensure documentation clearly shows timeline and objective evidence (e.g., DEXA results, clinical notes, allergy/adverse reaction details, medication history)

Documentation Required

Required supporting clinical documentation

Documentation submitted should include evidence of inadequate response (most recent DEXA scan), documented contraindication or drug interaction, or details of intolerance, to support approval of the branded bisphosphonate after step therapy.

Most recent DEXA scan or other objective evidence of treatment failure
Clinical notes describing contraindication or drug interaction
Notes detailing intolerance (side effects, severity, discontinuation date)

Background

Bisphosphonates are a class of medications used to treat osteoporosis and related bone density loss. Assessment of treatment response is commonly performed with DEXA scans; this policy specifies that an inadequate treatment response should be determined by the most recent DEXA when used to justify coverage of a branded bisphosphonate. The policy implements a branded-over-generic step therapy approach administered by CVS Caremark: if the patient filled a qualifying supply of a generic bisphosphonate within the prior lookback period, a prior authorization message will be generated and the post-step-therapy PA criteria (failure, contraindication/interaction, or intolerance to >=1 generic bisphosphonate) must be documented and submitted for review.

Definitions

inv-11: Step therapy (post step therapy prior authorization)

DefinitionRequirement that the patient trial at least one generic bisphosphonate (filled >=28-day supply within the prior 365 days) before coverage of a branded bisphosphonate is considered.

Acceptable exceptionsDocumented contraindication, potential drug interaction, or intolerance to at least one generic bisphosphonate may substitute for a prior fill trial.

Trigger for PAIf a qualifying generic fill is present in the prior 365 days, the branded request will generate a PA requirement and be evaluated against post-step-therapy criteria.

Evidence requiredClinical documentation such as most recent DEXA (for inadequate response), or documentation of contraindication/intolerance, should be submitted for PA review.

Step Therapy Details

Step	Requirement	Evidence needed	Coverage status
1
Patient must have tried at least one generic bisphosphonate: filled >=28-day supply within the prior 365 days under a prescription benefit administered by CVS Caremark, OR have a documented contraindication or intolerance to at least one generic bisphosphonate
For prior trial: pharmacy fill history showing >=28-day supply within past 365 days. For inadequate response: most recent DEXA demonstrating insufficient response. For contraindication/interaction or intolerance: clinical documentation explaining the contraindication, interaction, or intolerance
Covered with post-step-therapy prior authorization when requirements met