CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Generic Step Therapy Plans — Insomnia Agents

Defines CVS Caremark-administered generic step therapy and post-step prior authorization requirements for branded insomnia agents under the prescription benefit, including approval durations and coverage criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneric Step Therapy Plans — Insomnia Agents

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf the patient has not filled a 30-day supply of a generic non‑benzodiazepine hypnotic within the past 180 days, submit a prior authorization documenting inadequate response, contraindication, intolerance, or interaction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysminimum trial length

180 dayslook-back period

24 monthsapproval duration

3referenced policies

Coverage Criteria

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Post Step Therapy Prior Authorization Criteria

Covered with post step therapy prior authorization when ANY of the following are met:

Post-step coverage criteria: (1) Inadequate treatment response after at least a 30-day trial of at least one generic non-benzodiazepine hypnotic drug; (2) Documented contraindication or potential drug interaction that would prohibit a trial of at least one generic non-benzodiazepine hypnotic drug; (3) Intolerance to at least one generic non-benzodiazepine hypnotic drug.

Meeting any one of these criteria allows coverage with post-step therapy prior authorization.

Initial Step Requirement

Initial step therapy requirement to avoid PA:

Initial Step: Patient has filled a prescription for at least a 30-day supply of at least one generic non-benzodiazepine hypnotic drug within the past 180 days under a prescription benefit administered by CVS Caremark.30 days; 180 days look-back

If this requirement is not met the claim will reject and a prior authorization is required.

Initial Therapy Criteria

Initial Step Therapy

Generic fill prerequisite: Patient must have filled at least a 30-day supply of at least one generic non-benzodiazepine hypnotic within the past 180 days under a CVS Caremark prescription benefit to have branded insomnia agent paid without prior authorization.30 days; 180 days

If unmet, claim rejects and post-step prior authorization criteria apply.

Step Therapy Details

Requirement	Details
Initial step therapy prerequisite	Patient has filled a prescription for at least a 30‑day supply of at least one generic non‑benzodiazepine hypnotic within the past 180 days under a prescription benefit administered by CVS Caremark; if met, the requested branded insomnia drug will be paid without prior authorization. If not met, the claim will reject and a prior authorization is required.
Post‑step therapy prior authorization criteria (any of the following)	(1) Inadequate treatment response after ≥30‑day trial of ≥1 generic non‑benzodiazepine hypnotic; (2) Documented contraindication or potential drug interaction prohibiting trial of ≥1 generic non‑benzodiazepine hypnotic; (3) Intolerance to ≥1 generic non‑benzodiazepine hypnotic. Meeting any one criterion permits coverage with PA.

Policy Identifiers & Coding Notes

Policy Identifiersmixed

372-D	GSTP Insomnia Agents Policy identifier
406-D	GSTP Insomnia Agents Policy identifier
382-D	GSTP Insomnia Agents Policy identifier

Generic trial and look-back — Minimum 30-day trial within prior 180 days

Minimum trial length30 days

Look-back periodPrior 180 days

Required fillAt least one filled prescription for a generic non-benzodiazepine hypnotic

Provider Actions & Prior Authorization

Prior Authorization

Post-step therapy prior authorization required

If the patient has NOT met the initial step therapy requirement (see criteria below), the claim will reject and a prior authorization (PA) is required. Submit PA requests to the plan's PA unit for clinical review. Branded insomnia agents may be covered under the prescription benefit only after PA approval.

Claims will reject if initial step therapy is not met and will require prior authorization
PA requests must include supporting documentation of the reason the initial step cannot be met

Step Therapy

Initial Step Requirement

Initial step: patient must have filled at least a 30-day supply of at least one generic non‑benzodiazepine hypnotic within the past 180 days under the plan's prescription benefit administered by CVS Caremark. If this requirement is met, the requested branded drug may be processed under the prescription benefit without PA.

30-day supply of a generic non-benzodiazepine hypnotic filled within the past 180 days

Documentation Required

Supporting clinical rationale

Documentation submitted with a PA must support one of the following: inadequate response to an adequate trial (≥30 days) of at least one generic non‑benzodiazepine hypnotic; documented contraindication or clinically significant potential drug interaction to all reasonable generic non‑benzodiazepine hypnotic options; or documented intolerance (adverse reaction) to at least one generic non‑benzodiazepine hypnotic. Provide medication fill history, clinical notes, lab results or consultation notes as applicable.

Inadequate response after ≥30-day trial of a generic non-benzodiazepine hypnotic
Documented contraindication or potential drug interaction to generic non-benzodiazepine hypnotics
Documented intolerance/adverse reaction to a generic non-benzodiazepine hypnotic
Include medication fill history and supporting clinical documentation

Denial Risk

Initial step therapy requirement

Claims will reject and require prior authorization if the patient has not filled a 30-day supply of at least one generic non‑benzodiazepine hypnotic within the past 180 days, unless documentation meets one of the supporting clinical rationale criteria above.

Rejection occurs when no 30-day generic non-benzodiazepine hypnotic fill in past 180 days is found
PA may be approved only if supporting clinical rationale is documented

Definitions

GSTP — Generic Step Therapy Plans (branded insomnia agents subject to step requirements)

Program nameGSTP (Generic Step Therapy Plans) administered by CVS Caremark

Branded products subject to GSTPEdluar, Zolpimist, Belsomra, Dayvigo, Quviviq

Policy referencesGSTP Insomnia Agents Policy 372-D, 406-D, 382-D

Generic non-benzodiazepine hypnotic — Definition and required trial

Class definitionGeneric non-benzodiazepine hypnotics: generic insomnia medications that must be trialed or shown unsuitable before certain branded insomnia agents are covered

Failure criteriaInadequate response after at least a 30-day trial of at least one generic non-benzodiazepine hypnotic

Alternate pathwaysDocumented contraindication, potential drug interaction, or intolerance to at least one generic non-benzodiazepine hypnotic

Background

This Generic Step Therapy Plan (GSTP) applies to insomnia agents and implements a generic‑first step therapy approach under the CVS Caremark prescription benefit. To avoid prior authorization for specified branded insomnia drugs, the patient must have filled at least a 30‑day supply of one or more generic non‑benzodiazepine hypnotics within the prior 180 days.

If the initial step requirement is not met, the claim will reject and the branded insomnia agent may be covered only with a post‑step therapy prior authorization when documentation shows any of the following: inadequate response after a ≥30‑day trial of a generic non‑benzodiazepine hypnotic; a documented contraindication or potential drug interaction preventing trial of a generic non‑benzodiazepine hypnotic; or documented intolerance to a generic non‑benzodiazepine hypnotic.

Because this GSTP references CVS Caremark clinical criteria, the generic‑first requirement and the list of products subject to step therapy may change with market events or CVS Caremark updates.