CurrentPriority HealthPolicy ID: 26328, Version 15

2026 Medicare Part D step therapy criteria

A Priority Health Medicare Part D step therapy criteria list specifying prerequisite drug trials or alternatives required before coverage of listed outpatient prescription drugs (multiple products with drug-specific prior-try requirements). Applies to Medicare Part D plans covered by Priority Health.

Policy Summary

PayerPriority Health

Policy2026 Medicare Part D step therapy criteria

Policy CodePolicy ID: 26328, Version 15

Change TypeClarified (document lists criteria and index)

Effective Date

Next Review Date

Key ActionPrescribers must document prior trials or claims showing the required alternative generic drugs were used (including duration where specified) before coverage for the listed agent will be granted.

SourceLink

POLICY UPDATE CHANGES

Document lists 2026 Medicare Part D step therapy criteria with drug-specific prerequisite requirements and an alphabetical index.

11+Drugs listed with step requirements

Summary of changes and scope

This bulletin summarizes Priority Health's Medicare Part D step therapy (prior trial) policy for 2026: a drug-specific list of outpatient prescription products that require documented prior trials or specified alternative agents before coverage. Policy number: ID: 26328, Version 15. Status: CURRENT. Changes: Last updated June 2026 (see document-level changes list for the single change note).

Step therapy prerequisite criteria (drug-specific)

This section lists Medicare Part D drugs subject to required prior trials or specified alternative agents under Priority Health. The detailed criteria trees below encode the exact prerequisite requirements (which drug(s) must be tried first and any numeric n-of rules) and the required trial durations where specified.

Calcitriol ointment 3 mcg/gm external

Must first try:

Patient must first try calcipotriene

DIFICID (fidaxomicin) suspension reconstituted 40 mg/mL oral or DIFICID tablet 200 mg oral

Must first try:

Patient must first try vancomycin

Difluprednate emulsion 0.05% ophthalmic

Must first try:

Must first try one other generic steroid eye drop

Febuxostat tablets 40 mg and 80 mg oral

Must first try:

Must first try allopurinol

Fetzima (levomilnacipran) extended-release capsules (20, 40, 80, 120 mg)

Coverage requires prior trial:

Must have claim or confirmed trial for at least 28-days with 2 of the following generic antidepressants: duloxetine, venlafaxine (IR or XR), or desvenlafaxine>= 28 days

Paliperidone ER tablets

Must have prior trials:

Must have claim or confirmed trial with two of the following generic drugs for at least 28 days each: aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone>= 28 days each

Travoprost (BAK-free) solution 0.004% ophthalmic

Must first try:

Patient must first try latanoprost

Trintellix (vortioxetine) tablets 5 mg, 10 mg, 20 mg

Coverage requires prior trials:

Must have claim or confirmed trial for at least 28-days with 2 of the following generic antidepressants: duloxetine, venlafaxine (IR or XR), or desvenlafaxine>= 28 days

Vilazodone HCl tablets 10 mg, 20 mg, 40 mg

Coverage requires prior trials:

Must have claim or confirmed trial for at least 28-days with 2 of the following generic antidepressants: duloxetine, venlafaxine (IR or ER), or desvenlafaxine>= 28 days

What clinicians and billers must do

Step Therapy

Step therapy prerequisite trials required

Prescribers must document prior trials or claims showing the required alternative generic drugs were used (including duration where specified) before coverage for the listed agent will be granted.

Applies to listed agents in COVERAGE section

Documentation Required

Trial documentation duration

For specified antidepressants and selected antipsychotics, trials must be documented for at least 28 days each or by a claim confirming that trial.

Antidepressant trial duration >= 28 days

Policy Summary

PayerPriority Health

Policy2026 Medicare Part D step therapy criteria

Policy CodePolicy ID: 26328, Version 15

Change TypeClarified (document lists criteria and index)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

2026 Medicare Part D step therapy criteria

Summary of changes and scope

Step therapy prerequisite criteria (drug-specific)

Listed products and codes

What clinicians and billers must do

Key actions and effective timing

Document updates