CurrentNeighborhood Health Plan of Rhode IslandPolicy 374-D, 409-D, 384-D 07-2022

Generic step therapy for SSRIs (branded SSRI coverage)

Defines initial step therapy and post-step prior authorization requirements for branded selective serotonin reuptake inhibitors (SSRIs) under the CVS/caremark-administered prescription benefit for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneric step therapy for SSRIs (branded SSRI coverage)

Policy CodePolicy 374-D, 409-D, 384-D 07-2022

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnsure the patient has a filled ≥30-day supply of at least one generic SSRI within the prior 365 days to bypass prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysrequired minimum generic SSRI trial duration

365 dayslookback period

3policy identifiers

Coverage Criteria for Branded SSRIs

Post-step prior authorization coverage criteria

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Inadequate response: Patient has experienced an inadequate treatment response after at least a 30 day trial of at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) drug>= 30 days trial

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Contraindication or interaction: Patient has a documented contraindication or a potential drug interaction that would prohibit a trial with at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) drugN/A

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Intolerance: Patient has experienced an intolerance to at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) drugN/A

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Initial Step

Initial step therapy requirement to avoid PA

Initial fill requirement: Patient has filled a prescription for at least a 30 day supply of at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) drug within the past 365 days under a prescription benefit administered by CVS/caremark30 days within 365 days

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Initial Therapy Requirement

Initial therapy

Initial therapy requirement to permit coverage of branded SSRI without PA

Initial generic trial: Filled prescription for a >= 30 day supply of at least one generic SSRI within the prior 365 days under a CVS/caremark-administered prescription benefit>= 30 days within 365 days

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Step Therapy Table

Step	Requirement to Bypass Prior Authorization	If Requirement Not Met (PA criteria / approval conditions)
1	Filled prescription for at least a 30‑day supply of at least one generic SSRI within the prior 365 days under a CVS/caremark‑administered prescription benefit	Claim will reject and prior authorization is required; branded SSRI may be approved under PA when ANY of the following are documented: inadequate response after ≥30‑day trial of a generic SSRI; a documented contraindication or potential drug interaction to a generic SSRI; or intolerance to a generic SSRI.

Key Coding and Lookback Values

inv-03: Generic SSRI trial duration — >= 30 days

Minimum trial duration>= 30 days

Applies toAt least one generic SSRI drug

PurposeRequired trial length to demonstrate inadequate treatment response before branded SSRI PA

inv-04: Medication history lookback — 365 days

Lookback period365 days

ScopeVerify filled prescription for at least a 30-day supply of a generic SSRI within this period

Benefit administratorUnder a prescription benefit administered by CVS/caremark

Provider Actions and Prior Authorization

Step Therapy

Initial Step Requirement

Initial Step Requirement — A filled prescription for at least a 30-day supply of at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) within the prior 365 days under the prescription benefit administered by CVS/caremark is required. If this initial step criterion is met, the requested branded SSRI will be paid under the prescription benefit.

Affected drugs: generic SSRIs (30-day supply within past 365 days)
Operational note: Verification is performed against CVS/caremark prescription benefit records

Prior Authorization

Post-step prior authorization

Post-step prior authorization — If the patient does NOT meet the initial step requirement, the claim will reject with a message that a prior authorization (PA) is required. Branded SSRIs will be considered for coverage under PA when documentation shows inadequate response to a generic SSRI after at least a 30-day trial, a documented contraindication or drug interaction to generic SSRI use, or intolerance to at least one generic SSRI.

PA criteria include: inadequate treatment response after ≥30-day trial of a generic SSRI; OR documented contraindication/drug interaction to generic SSRI; OR intolerance to ≥1 generic SSRI.
Claims will reject at point-of-sale if initial step not met and prompt PA submission.

Documentation Required

Required documentation

Required documentation — Documentation submitted with a PA request should demonstrate either a filled prescription for a 30-day supply of a generic SSRI within the prior 365 days or clinical evidence supporting PA criteria (e.g., chart notes documenting inadequate response after a ≥30-day trial, documentation of contraindication or drug interaction, or evidence of intolerance).

Acceptable evidence: pharmacy claim showing 30-day generic SSRI fill within past 365 days; clinical chart notes describing trial duration and outcome; medication history indicating intolerance or adverse reaction; documentation of contraindicating condition or interacting medication.

Denial Risk

Initial step failure triggers PA

Initial step failure triggers PA — Claims will reject at point-of-sale if the patient has not filled a 30-day supply of at least one generic SSRI within the past 365 days, prompting submission of a prior authorization request for review against the PA criteria.

Rejection message: prior authorization required
Next step: submit PA with supporting documentation as noted above.

Background

Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medications commonly used to treat depressive and anxiety disorders. This policy applies a formulary step therapy approach under the CVS/caremark-administered prescription benefit to encourage trials of available generic SSRIs before coverage of branded SSRI products such as Pexeva and Trintellix.