Step therapy criteria for prescription drugs
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A directory-style step therapy list describing drugs that have written coverage determination policies under Providence Health Plan; intended for providers and pharmacy staff to identify which medications are subject to step therapy restrictions and where to verify coverage.
No material clinical or coverage changes in this revision.
Coverage & Scope
General scope (informational)
Drugs are listed as having written coverage determination policies; specific coverage requires checking the formulary or the individual drug policy.
Providers must verify coverage, step therapy requirements, prior authorization, and any restrictions by checking the member formulary, the individual drug coverage policy, or by contacting Providence Health Plan Customer Service.
This document is a directory-style listing of drugs that have written coverage determination policies under Providence Health Plan’s step therapy program. Listing on this document does not imply the drug is covered under the prescription drug benefit; coverage, prior authorization, step requirements, quantity limits, and other restrictions must be confirmed through the member’s formulary or the individual drug coverage policy.
Providers are responsible for verifying coverage and any prior authorization or step-therapy requirements by consulting the formulary and member handbook or by contacting Providence Health Plan Customer Service at the numbers shown in the plan materials.
Product Strengths and Codes
| 200 mg, 400 mg, 600 mg, 800 mg | eslicarbazepine oral tablet strengths |
| 200 MG, 400 MG, 600 MG, 800 MG | APTIOM ORAL TABLET strengths (as listed) |
| 10 mg/ml | brivaracetam oral solution concentration |
| 40 mg/ml | rufinamide oral suspension concentration |
| 250MG/DAY, 350 MG/DAY, 100 MG, 150 MG, 25 MG, 50 MG, 200 MG | XCOPRI (cenobamate) various tablet strengths and maintenance/titration pack descriptors |
| 0.01 %, 0.03 %, 0.0015 %, 0.005 %, 0.002 %, 0.024 %, 0.02 % | ophthalmic agent concentrations listed (bimatoprost, tafluprost, IYUZEH, LUMIGAN, OMLONTI, VYZULTA, RHOPRESSA, ZIOPTAN) |
| 25 mg | sitagliptin oral tablet strength |
| 6 MG/0.6 ML | G-CSF products prefilled syringe/auto-injector strengths (Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo) |
| 10 mg, 15 mg, 25 mg, 5 mg | leucovorin calcium oral tablet strengths listed |
| 185 MG | PIVYA oral tablet 185 mg |
| 100-62.5-25 MCG, 200-62.5-25 MCG | Trelegy Ellipta inhalation blister strengths |
| 600 mg | zileuton oral tablet 600 mg (12 hr) |
Provider Instructions & Notices
Step therapy / prior authorization advisory
Drugs listed on this step therapy document have written coverage determination policies; providers must verify whether a drug is covered and whether prior authorization or other step requirements apply before prescribing or dispensing.
- Verify coverage and any prior authorization requirements through the member formulary or the individual drug coverage policy.
- If unclear, contact Providence Health Plan Customer Service for benefit details and prior authorization instructions.
List-level step therapy notice
This document enumerates specific drugs and formulations that are subject to step therapy policies; it does not provide fail‑first steps, exact step requirements, or detailed prior authorization criteria — those are defined in the formulary or each drug’s individual coverage policy.
- Listed products include antiepileptic medications, ophthalmic glaucoma agents, DPP‑4 inhibitors, G‑CSF products, leucovorin, inhaled combination therapy (Trelegy), and zileuton.
- Confirm the required step(s) and any acceptable alternatives in the formulary or the drug’s coverage policy before treatment.
Verify coverage via formulary / Customer Service
Providers must verify drug coverage by checking the member’s formulary and member handbook; for questions about benefits, coverage, or authorization procedures contact Providence Health Plan Customer Service.
- Customer Service: 503-574-7500 or 1-800-878-4445 (TTY: 711), Monday–Friday, 8 a.m.–6 p.m.
- Use the formulary and individual drug coverage policy to determine coverage, step requirements, and prior authorization processes.
Coverage verification required — coverage not guaranteed
Listing on this document does not guarantee coverage under the prescription drug benefit; providers must confirm benefit and coverage details for each member prior to prescribing or dispensing.
- Additional restrictions and exclusions may apply and must be checked in the member’s formulary or handbook.
- Contact Customer Service for verification of benefits and coverage specifics.
Background & Purpose
This document is primarily administrative: it identifies drugs and formulations that are subject to written coverage determination policies under step therapy. It does not provide clinical rationale, detailed step-failure criteria, or the specific prior authorization rules for individual products.
For each listed drug, providers should verify benefit coverage and any step therapy or prior authorization requirements by checking the member formulary or the individual drug policy. Additional restrictions and exclusions may apply; contact Providence Health Plan Customer Service for benefit and coverage details.
Key Definitions
Step Therapy List Overview
| Drug / Formulation | Step therapy note |
|---|---|
| eslicarbazepine (Aptiom) oral tablet — 200 mg, 400 mg, 600 mg, 800 mg | Listed as subject to step therapy; specific step requirements and any prior authorization must be verified in the formulary or the individual drug coverage policy. |
| brivaracetam (Briviact) oral solution — 10 mg/mL | Listed as subject to step therapy; confirm fail‑first steps or PA requirements via formulary or individual policy. |
| rufinamide oral suspension — 40 mg/mL; oral tablets — 200 mg, 400 mg | Included on the step therapy list; providers must verify specific step requirements and prior authorization rules in the formulary or drug policy. |
| cenobamate (Xcopri) — multiple strengths and titration/maintenance packs (25 mg–350 mg; titration and maintenance packs listed) | Subject to step therapy listing; check the formulary or Xcopri coverage policy for required prior therapy steps and PA criteria. |
| Antiglaucoma ophthalmic agents — bimatoprost (0.01%, 0.03%), tafluprost (0.0015%), Iyuzeh (0.005%), Lumigan 0.01%, Omlonti (0.002%), Vyzulta (0.024%), Zioptan (0.0015%), Rhopressa (0.02%) | These ophthalmic products are listed as subject to step therapy; verify any required first‑line alternatives or PA via the formulary or product policy. |
| sitagliptin — oral tablet 25 mg (DPP‑4 inhibitor class) | Listed under DPP‑4 inhibitors subject to step therapy; confirm step or PA requirements in the formulary or specific coverage policy. |
| G‑CSF products — Fylnetra, Nyvepria, Stimufend, Udenyca, Ziextenzo (all listed as 6 mg/0.6 mL prefilled syringes/auto‑injectors/on‑body delivery) | G‑CSF agents are included on the step therapy list; prior authorization or step requirements must be confirmed in formulary or individual policy. |
| Leucovorin — oral tablet 5 mg, 10 mg, 15 mg, 25 mg; Pivya 185 mg | Leucovorin products are listed as subject to step therapy; check the formulary or Pivya coverage policy for any PA or step requirements. |
| Trelegy Ellipta inhalation — 100‑62.5‑25 mcg and 200‑62.5‑25 mcg blister strengths | Trelegy is listed on the step therapy document; specific step therapy and prior authorization criteria are defined in the formulary or the Trelegy policy. |
| zileuton (Zyflo) — oral tablet 600 mg (12‑hour formulation) | Listed as subject to step therapy; verify any required prior therapies or PA via the formulary or the Zyflo coverage policy. |
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