CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Branded bisphosphonate coverage (step therapy and PA)

Defines initial step therapy and post-step-therapy prior authorization rules for branded bisphosphonates administered under the CVS Caremark prescription benefit; affects prescribers and pharmacists for Neighborhood Health Plan of Rhode Island members whose pharmacy benefit is managed by CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBranded bisphosphonate coverage (step therapy and PA)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf initial step therapy criteria are not met, submit a prior authorization and provide documentation of inadequate response, contraindication/interaction, or intolerance to a generic bisphosphonate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

28 daysminimum generic bisphosphonate fill

365 dayslookback period

post-step PAcoverage pathway

at least onerequired trial

Coverage Criteria

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Post-step therapy prior authorization - approval criteria

Covered when ONE of the following is met:

Post-step PA criteria: Patient has experienced an inadequate treatment response (as determined on most recent DEXA scan) after a sufficient trial of a generic bisphosphonate drug

Post-step PA criteria: Patient has a documented contraindication or potential drug interaction that would prohibit a trial with at least one generic bisphosphonate drug

Post-step PA criteria: Patient has experienced an intolerance to at least one generic bisphosphonate drug

Requirement	Details
Trial of at least one generic bisphosphonate
Member must have filled a prescription for at least a 28‑day supply of at least one generic bisphosphonate within the past 365 days under a prescription benefit administered by CVS Caremark; if not met, the claim will reject and a prior authorization is required.

Provider Actions and Prior Authorization

Step Therapy

Initial Step Therapy Requirement

If the patient has filled a prescription for at least a 28-day supply of at least one generic bisphosphonate within the past 365 days under a prescription benefit administered by CVS Caremark, the requested branded bisphosphonate will be paid under that prescription benefit and no prior authorization is required.

Requirement applies to fills processed under CVS Caremark within prior 365 days
Minimum filled supply: ≥28 days

Prior Authorization

Post-step therapy prior authorization

If the initial step therapy requirement is not met, the claim will reject with an explanation that a prior authorization (PA) is required. Submit a PA to the plan's prior authorization unit for review; the PA will be evaluated against the post-step therapy coverage criteria.

Claims rejecting for unmet step therapy will require PA submission
PA requests are evaluated against the coverage criteria below

Documentation Required

Required supporting documentation

Documentation supporting the medical necessity of a branded bisphosphonate must be provided with the PA request. Acceptable supporting documentation includes the most recent DEXA scan showing inadequate treatment response, clinical notes documenting contraindication or potential drug interaction to generic bisphosphonates, or records of intolerance to at least one generic bisphosphonate.

Most recent DEXA scan for inadequate response
Clinical documentation of contraindication or drug interaction
Evidence of intolerance to a generic bisphosphonate

Denial Risk

Initial step therapy rejection trigger

Claims will be rejected and require prior authorization if the patient has not filled at least a 28-day supply of a generic bisphosphonate within the past 365 days under CVS Caremark. Providers should confirm pharmacy benefit history before submitting a claim to avoid denials.

Claim rejection trigger: no ≥28-day generic bisphosphonate fill in prior 365 days under CVS Caremark
Confirm pharmacy benefit history prior to submission

Coding and Administrative Parameters

inv-02: Minimum fill duration

Minimum fill duration>= 28 days

ContextMust be a single prescription fill for at least a 28‑day supply of a generic bisphosphonate

Benefit administratorApplies when filled under a CVS Caremark‑administered prescription benefit

inv-03: Lookback period for prior generic fill

Lookback period for prior generic fill365 days

Applies toAny filled prescription for a generic bisphosphonate within the past 365 days

PurposeDetermines eligibility to bypass prior authorization for branded bisphosphonates

Definitions

inv-09: Inadequate treatment response

DefinitionInadequate treatment response: as determined on most recent DEXA scan.

ContextUsed as one of the criteria to approve post‑step therapy prior authorization for branded bisphosphonates

DocumentationMost recent DEXA scan demonstrating inadequate response is required for PA evaluation

inv-10: Intolerance

DefinitionIntolerance: documented inability to tolerate at least one generic bisphosphonate.

ContextIntolerance to a generic bisphosphonate is an approvable criterion for post‑step therapy PA for branded agents

DocumentationMedical record documentation of intolerance to at least one generic bisphosphonate must be provided for PA

Background

Bisphosphonates are medications used to treat osteoporosis and other conditions affecting bone density. This policy applies to branded bisphosphonates (for example, Binosto and Fosamax Plus D) dispensed under the CVS Caremark-administered prescription benefit and establishes both an initial step therapy requirement and a post-step therapy prior authorization pathway.

Under the initial step therapy rule, members who have filled a prescription for at least a 28-day supply of one or more generic bisphosphonates within the prior 365 days under the CVS Caremark benefit will have the requested branded bisphosphonate paid without a prior authorization; claims will reject and require PA if that criterion is not met.

When initial step therapy criteria are not met, branded bisphosphonates remain covered with post-step therapy prior authorization if documentation demonstrates one of the following: (1) an inadequate treatment response as determined by the most recent DEXA scan after a sufficient trial of a generic bisphosphonate; (2) a documented contraindication or potential drug interaction that precludes trial of at least one generic bisphosphonate; or (3) documented intolerance to at least one generic bisphosphonate.