Step therapy criteria for pharmacy-covered drugs
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Defines step therapy (prior authorization and step requirements) for various pharmacy and specialty drugs covered under Providence Health Plan's pharmacy benefit; applies to providers prescribing these medications for plan members.
No material clinical or coverage changes in this revision.
Coverage criteria overview
Step therapy applicability — general
Drugs enumerated in this document are subject to Providence Health Plan step therapy rules; specific step sequences, required trials, durations, and failure definitions are not detailed in the provided text and must be verified via the plan's Drug Search tool or full policy details.
This document lists multiple drug classes and specific formulations (for example: antiepileptic agents such as perampanel/FYCOMPA, eslicarbazepine/APTIOM, brivaracetam/BRIVIACT, rufinamide/BANZEL, cenobamate/XCOPRI; glaucoma agents including bimatoprost, tafluprost, VYZULTA; stimulatory factors/G-CSF products; phosphate binders such as AURYXIA, VELPHORO, lanthanum, sevelamer; topical agents such as ivermectin/SOOLANTRA; and others). Providers must confirm plan-specific step requirements for the listed drug.
Drugs enumerated in this document are subject to Providence Health Plan step therapy criteria when covered under the pharmacy benefit. The listing groups multiple drug classes and specific formulations that may be subject to step requirements; however, specific step sequences, required trials, durations, and failure definitions are not provided in the excerpt. Providers must consult the plan’s full policy and formulary tools (for example, the online Drug Search) to determine the precise step-therapy requirements that apply to a particular drug and member.
The provided document excerpt does not include an explicit list of conditions or situations designated as not medically necessary for the drugs covered by these step therapy criteria. Additionally, the policy states that additional restrictions and exclusions to drug coverage may apply, and that coverage is not guaranteed — providers and members should verify benefits via the Drug Search tool, the member handbook, or by contacting Providence Customer Service.
Listed drug formulations and code groups
| perampanel oral suspension 0.5 mg/ml | listed formulation |
| perampanel oral tablet 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg | listed formulations |
| FYCOMPA ORAL SUSPENSION 0.5 MG/ML | listed formulation |
| FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG, 8 MG, 10 MG, 12 MG | listed formulations |
| eslicarbazepine oral tablet 200 mg, 400 mg, 600 mg, 800 mg | listed formulations (APTIOM) |
| brivaracetam oral solution 10 mg/ml | BRIVIACT oral solution |
| rufinamide oral suspension 40 mg/ml | BANZEL ORAL SUSPENSION 40 MG/ML |
| rufinamide oral tablet 200 mg, 400 mg | BANZEL ORAL TABLET 200 MG, 400 MG |
| XCOPRI oral tablets and titration/maintenance packs (25-350 mg dosing packs) | XCOPRI ORAL TABLET 25 MG, 50 MG, 100 MG, 150 MG, 200 MG and titration/maintenance packs including 12.5 mg, 25 mg, 50 mg, 100 mg, 150 mg, 200 mg dose packs |
| bimatoprost ophthalmic drops 0.01%, 0.03% | bimatoprost formulations |
| FYLNETRA, NYVEPRIA, STIMUFEND, UDENYCA, ZIEXTENZO | G-CSF stimulating factor subcutaneous syringes (6 mg/0.6 mL) |
| leucovorin calcium oral tablets 5 mg, 10 mg, 15 mg, 25 mg | leucovorin formulations |
| NEUPRO transdermal patch 1 mg/24h – 8 mg/24h | NEUPRO transdermal patch strengths |
| ferric citrate oral tablet 210 mg (AURYXIA) | AURYXIA oral tablet 210 mg iron |
| VELPHORO chewable 500 mg | VELPHORO chewable tablet 500 mg |
| lanthanum chewable 500 mg, 750 mg, 1000 mg | lanthanum chewable tablet strengths |
| sevelamer carbonate powder 0.8g, 2.4g | sevelamer carbonate oral powder in packet |
| sevelamer HCl 400 mg, 800 mg | sevelamer HCl oral tablets |
| FOSRENOL 750 mg, 1000 mg | FOSRENOL oral powder in packet / chewable tablet strengths |
Provider responsibilities and actions
Prior authorization may be required
Certain drugs listed in this step therapy criteria may require prior authorization under the pharmacy benefit; providers should verify prior authorization requirements and submit required documentation per plan procedures.
Drugs listed for step therapy review
This document enumerates drug classes and individual agents that are subject to step therapy review; examples include multiple antiepileptic medications (perampanel, eslicarbazepine, brivaracetam, rufinamide, cenobamate) and glaucoma agents (bimatoprost, tafluprost, VYZULTA) as listed in the policy.
- Antiepileptic agents: perampanel (FYCOMPA), eslicarbazepine (APTIOM), brivaracetam (BRIVIACT), rufinamide (BANZEL), cenobamate (XCOPRI)
- Glaucoma agents: bimatoprost (various concentrations/brands), tafluprost (PF), VYZULTA
Verify coverage and benefits
Verify member coverage and benefits before prescribing or dispensing: use the Providence Drug Search formulary tool or check the member handbook; contact Providence Customer Service for benefit verification if needed.
- Drug Search: https://www.providencehealthplan.com/members/pharmacy-resources
- Customer Service: 503-574-7500 or 1-800-878-4445 (TTY: 711), Mon–Fri 8 a.m.–6 p.m.
Coverage contingent on plan rules
Coverage of the drugs listed is subject to applicable plan restrictions and exclusions and is not a guarantee of coverage; prior authorization or member benefit verification may be required.
Background and scope
This policy groups multiple drug classes under a single step therapy framework. Examples include several antiepileptic medications, various glaucoma agents, phosphate binders, hematopoietic growth factors, stimulants and certain topical agents. The document lists specific formulations within those classes that are subject to step therapy, but does not provide drug-by-drug step sequences or failure definitions in the excerpt.
Initial therapy — step definitions
Initial therapy listing (unspecified)
No explicit initial-step therapy agent or required first-line trial is defined in the provided excerpt.
Providers must consult the full policy text or the plan's Drug Search tool / formulary for plan-specific initial-step requirements and any preferred alternatives
Step therapy details
| Drug / Drug Group | Step Therapy Requirement | Required Trial / Duration | Failure Definition |
|---|---|---|---|
| Antiepileptic medications (examples: perampanel [FYCOMPA] suspension/tablets; eslicarbazepine [APTIOM] tablets; brivaracetam [BRIVIACT] solution; rufinamide [BANZEL] suspension/tablets; cenobamate [XCOPRI] tablets and titration/maintenance packs) | |||
| These agents are included on the plan's step therapy listing and are subject to step therapy rules under the pharmacy benefit. | |||
| Specific required trial agents and durations are not specified in the provided text; providers must verify plan-specific step requirements through the Drug Search tool or full policy. | |||
| Failure criteria are not defined in the provided excerpt; consult the full policy or formulary tool for failure definitions. |
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