Step therapy criteria for prescription drugs
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Lists drugs subject to Providence Health Plan's step therapy review and informs providers/members that listed drugs have written coverage determination policies; coverage depends on formulary and member handbook. Applies to Providence Health Plan prescription drug benefit management.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
Listing a drug on this document does not guarantee it will be covered under the Providence Health Plan prescription drug benefit. Providers and members must verify drug coverage by checking the member's formulary and member handbook, because additional restrictions and exclusions may apply. For coverage questions, contact Customer Service at the numbers provided in the plan materials.
Provider Actions & Verification
Prior authorization / step edits may apply
This document is a complete list of drugs that have written coverage determination policies; prior authorization or step edits may apply per the formulary—verify on a per‑drug basis.
Step therapy criteria applied by therapeutic class
Step therapy criteria are applied to the drugs listed and are organized by therapeutic class (examples include antiepileptic medications, anti‑glaucoma agents, DPP‑4 inhibitors, and granulocyte colony‑stimulating factors).
- Antiepileptic medications (multiple eslicarbazepine, brivaracetam, rufinamide, cenobamate entries)
- Anti‑glaucoma agents (bimatoprost, tafluprost, IYUZEH, Vyzulta, Zioptan, Rhopressa, etc.)
- DPP‑4 inhibitors (sitagliptin 25 mg listed)
- Granulocyte colony‑stimulating factors (Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo)
Verify coverage via formulary and member handbook
Providers and members must verify drug coverage by checking the formulary and member handbook; contact Customer Service with questions about covered drugs at (503) 488-2800 or Toll-Free (855) 722-8205 (TTY/TDD: 711), Monday–Friday 8 a.m.–5 p.m.
Listed drugs are not guaranteed to be covered
Listing a drug on this step therapy document does not guarantee coverage under the prescription drug benefit; lack of formulary coverage or additional restrictions and exclusions may result in denial or require alternative therapies.
- Additional restrictions and exclusions may apply and must be confirmed on a per‑drug basis.
- Coverage determinations are subject to the member's formulary and benefit design.
Definitions
Background
This document is an administrative list of drugs that are subject to Providence Health Plan step therapy and other written coverage‑determination policies. Drugs are grouped by therapeutic class (for example, antiepileptic medications, anti‑glaucoma agents, DPP‑4 inhibitors, and granulocyte colony‑stimulating factors) and include both brand and generic product names. The list identifies agents to which step therapy edits or prior authorization requirements may apply; it does not provide diagnosis‑specific clinical criteria or guarantee coverage.
Step Therapy List & Rules
| Therapeutic class | Drugs subject to step therapy |
|---|---|
| Antiepileptic medications | |
| eslicarbazepine oral tablet 200 mg, 400 mg, 600 mg, 800 mg; Aptiom (eslicarbazepine) oral tablet 200 mg, 400 mg, 600 mg, 800 mg; brivaracetam oral solution 10 mg/mL (Briviact); rufinamide oral suspension 40 mg/mL and tablets 200 mg, 400 mg; cenobamate (Xcopri) tablets and titration/maintenance packs (various strengths) | |
| Anti‑glaucoma agents | |
| bimatoprost ophthalmic drops 0.01% and 0.03% (Lumigan); tafluprost ophthalmic 0.0015% (PF); Iyuzeh (PF) ophthalmic 0.005%; Vyzulta ophthalmic drops 0.024%; Zioptan (PF) ophthalmic 0.0015%; Rhopressa ophthalmic drops 0.02%; Omlonti ophthalmic drops 0.002% | |
| DPP‑4 inhibitors | |
| sitagliptin oral tablet 25 mg | |
| Granulocyte colony‑stimulating factors (G‑CSF) | |
| Fylnetra subcutaneous syringe 6 mg/0.6 mL; Nyvepria subcutaneous syringe 6 mg/0.6 mL; Stimufend subcutaneous syringe 6 mg/0.6 mL; Udenyca autoinjector/on‑body 6 mg/0.6 mL; Ziextenzo subcutaneous syringe 6 mg/0.6 mL | |
| Leucovorin | |
| Leucovorin calcium oral tablets 5 mg, 10 mg, 15 mg, 25 mg; Pivya oral tablet 185 mg | |
| Other listed products | |
| Trelegy Ellipta inhalation blister with device (100-62.5-25 mcg; 200-62.5-25 mcg); zileuton extended‑release oral tablet 600 mg |
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