CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Step therapy requirements for selected outpatient drugs

Defines step therapy (prior authorization) requirements for specific branded and ODT formulations by requiring trial of specified generic alternatives (usually 30-day supply) before coverage. Affects prescribers and pharmacy prior authorization reviewers for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStep therapy requirements for selected outpatient drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least a 30-day trial of the specified generic alternative(s) before requesting coverage of the listed branded/ODT product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~10drug groups with step requirements listed

30-dayminimum required trial duration

severalODT products referenced

Step Therapy Coverage Criteria

Step therapy groups and required generic trials

Coverage will be provided when ALL of the following are met for each listed drug group:

ARIPIPRAZOLE ODT: At least a 30-day supply of generic aripiprazole immediate release tablet has been tried.30-day supply

source lists aripiprazole ODT requiring generic trial

BARACLUDE (ENTECAVIR): At least a 30-day supply of generic entecavir tablets has been tried.30-day supply

listed as BARACLUDE SOL group

BISPHOSPHONATES: At least a 30-day supply of alendronate, ibandronate, or risedronate has been tried.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStep therapy requirements for selected outpatient drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least a 30-day trial of the specified generic alternative(s) before requesting coverage of the listed branded/ODT product.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Step Therapy Details

Step therapy group	Required generic trial
ARIPIPRAZOLE ODT	At least a 30-day supply of generic aripiprazole immediate release tablet has been tried.
BARACLUDE (ENTECAVIR)	At least a 30-day supply of generic entecavir tablets has been tried.
BISPHOSPHONATES	At least a 30-day supply of alendronate, ibandronate, or risedronate has been tried.
BRINZOLAMIDE	At least a 30-day supply of dorzolamide 2% ophthalmic solution has been tried.
LAMOTRIGINE	At least a 30-day supply of generic lamotrigine immediate release tablets or generic lamotrigine chewable/dispersible tablet has been tried.
LEVALBUTEROL	At least a 30-day supply of albuterol HFA or Ventolin HFA has been tried.
OLANZAPINE ODT	At least a 30-day supply of generic olanzapine immediate release tablet has been tried.
PPI (ESOMEPRAZOLE)	At least a 30-day supply of two of the following generics — omeprazole capsules, pantoprazole tablets, or lansoprazole capsules — has been tried.
RISPERIDONE ODT	At least a 30-day supply of generic risperidone immediate release tablet has been tried.

Provider Requirements and Documentation

Prior Authorization

Prior authorization: 30-day generic trial required

Prior authorization requires documentation that the patient has tried a specified generic alternative for at least a 30-day supply before coverage of the requested agent will be approved.

Applies to all step therapy groups listed in policy (e.g., aripiprazole, entecavir, bisphosphonates, dorzolamide, lamotrigine, levalbuterol, olanzapine, PPIs, risperidone).
Acceptable documentation: medical record note, prior pharmacy fill history, prescription history showing a minimum 30-day supply, or pharmacy benefit data.
If multiple generic alternatives are listed for a group (e.g., PPIs), documentation must show trial of the required number of generics for the specified duration (e.g., two generics for 30 days each when stated).

Step Therapy

Step therapy enforcement

Prescriber must confirm the member has tried and either failed to achieve therapeutic effect or had intolerance to the listed generic alternatives (minimum 30-day supply) prior to coverage of the requested product.

Failure may be documented as lack of clinical response, adverse reaction, or contraindication to the generic alternative.
Include dates and duration of trial and clinical rationale for failure or intolerance.

Documentation Required

Required documentation of prior generic trial

Documentation submitted with the prior authorization request must clearly indicate a trial of at least a 30-day supply of the specified generic alternative medication(s) before coverage will be authorized.

Provide prescription records, pharmacy fill history, or clinician notes specifying product, dose, dates, and reason for discontinuation if applicable.
For groups requiring trials of two generics (where specified), documentation must show both trials were completed.

Denial Risk

Failure to document required generic trial

Coverage may be denied if a trial of the specified generic alternative(s) of at least a 30-day supply is not documented for the listed drugs.

Denial risk applies across all step therapy groups in this policy when the required generic trial documentation is absent.
If denied, an appeal or exception request must include the missing trial documentation or clinical justification for bypassing the step.

Coding & Trial Duration

Minimum trial duration

Minimum trial durationAt least a 30-day supply of the specified generic alternative(s) is required before coverage of the listed product.

PPI group requirementFor esomeprazole products, at least a 30-day supply of two of the following generics must be tried: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.

Single-generic alternativesFor most listed groups (e.g., aripiprazole ODT, entecavir, brinzolamide, lamotrigine ER, olanzapine ODT, risperidone ODT), at least a 30-day supply of the specified single generic alternative must be tried.

Bronchodilator alternativeFor levalbuterol tartrate HFA, at least a 30-day supply of albuterol HFA or Ventolin HFA must be tried.

Bisphosphonates groupFor bisphosphonates, at least a 30-day supply of alendronate, ibandronate, or risedronate must be tried.

Background

This policy establishes step therapy requirements that pair select branded or specialty formulations — including multiple orally disintegrating tablet (ODT) products — with one or more generic alternatives. For each listed step therapy group, coverage will be provided only after the member has tried the required generic alternative(s) for at least a 30-day supply as specified for that group.

The intent of these requirements is to manage utilization by requiring a trial of lower-cost generics prior to coverage of the requested branded/ODT product. Examples of affected groups include ODT products (aripiprazole, olanzapine, risperidone), antiviral and gastroenterology agents (entecavir, esomeprazole), and drug classes such as bisphosphonates and topical ophthalmic alternatives.

OpenPayer