CurrentSelectHealthPolicy N/A

SelectHealth step therapy list (partial)

SelectHealth step therapy requirements for multiple outpatient medications; lists medications subject to step therapy and the prior medication trials required for authorization.

Policy Summary

PayerSelectHealth

PolicySelectHealth step therapy list (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument prior trials of the specified alternative medications when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+distinct medication groups shown in this partial file

Mostrequire ≥1 prior trial of listed alternatives

13+medications listed with step therapy in this section

1entry exempting step for specific diagnosis

Coverage Criteria by Drug / Class

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Antiepileptic/antiseizure agents

Covered when ALL of the following are met

Antiepileptic/antiseizure agents (chunk 4): Previous trial on at least TWO of the following: carbamazepine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam (tablets or solution), oxcarbazepine IR, phenytoin, tiagabine, topiramate, valproic acid, zonisamide

Applies to medications listed in chunk 4

Antidepressants

Covered when ALL of the following are met

Antidepressant group (chunk 6): Previous trial on at least TWO of the following: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, venlafaxine (excluding 12.5 mg strength)

Applies to medications listed in chunk 6

Antipsychotics

Covered when ALL of the following are met

Antipsychotic group (chunk 8): Previous trial on at least ONE of the following: aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone

Applies to medications listed in chunk 8

Insomnia agent

Covered when ALL of the following are met

Insomnia agent (Belsomra) (chunk 10): Previous trial on at least ONE of the following: zolpidem IR, zolpidem ER, zaleplon, eszopiclone, temazepam, triazolam, ramelteon, trazodone

Applies to Belsomra

Bevespi Aerosphere

Covered when ALL of the following are met

Bevespi Aerosphere (chunk 12): Patient must try BOTH: Anoro AND Stiolto; Previous trial of mesalamine

Applies to Bevespi Aerosphere (mesalamine noted in source)

Amlodipine-atorvastatin combination

Covered when ALL of the following are met

Amlodipine-atorvastatin (chunk 14): Previous trial on at least ONE of the following statins: atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin; AND previous trial on amlodipine

Applies to amlodipine-atorvastatin combination

Tricyclic antidepressants

Covered when ALL of the following are met

Tricyclic antidepressants (chunk 16): Previous trial on at least ONE of the following: amitriptyline, amoxapine, desipramine, doxepin, imipramine, nortriptyline

Applies to listed tricyclic agents

Ivabradine (Corlanor)

Covered when ALL of the following are met

Ivabradine (Corlanor) (chunk 18): Previous trial on one of the following beta-blockers: metoprolol, nadolol, pindolol, propranolol, timolol; Exception for dilated cardiomyopathy in pediatric patients

Applies to ivabradine

Step therapy requirements (by medication)

Covered only after prior trials of specified agents are documented as follows (per medication):

Corlanor (ivabradine): Member must have tried metoprolol, nadolol, pindolol, propranolol, or timolol before Corlanor; exception for pediatric dilated cardiomyopathy.

Dapsone 5% gel: Previous use of topical clindamycin AND topical erythromycin; previous trial of tacrolimus; AND previous trial of at least one topical steroid from betamethasone, clobetasol, hydrocortisone, triamcinolone.

SEGLUROMET / SOLIQUA / STEGLATRO: Previous trial on metformin (including ER/solution) or listed metformin combinations OR pioglitazone/metformin.

DIFICID: Patient has tried oral vancomycin AND a previous trial on at least one of the listed ARBs or ARB-combination agents.

ASTAGRAF XL / ENVARSUS XR: Patient must have tried generic tacrolimus prior to these products.

EQUETRO: Previous trial on at least ONE of generic carbamazepine ER or generic carbamazepine IR.

FEMRING: Previous trial on estradiol cream.

GEMTESA: Previous trial on Myrbetriq AND one of solifenacin, darifenacin, or fesoterodine.

INCRUSE ELLIPTA: Patient must try Spiriva prior to coverage.

OMNARIS / QNASL / QNASL CHILDRENS: Previous trial on fluticasone, mometasone, or flunisolide.

Entry for medication in chunk 37

Covered when ALL of the following prior-trial requirements are met for the associated medication

Fluticasone/mometasone/flunisolide trial: Previous trial on: fluticasone, mometasone, or flunisolide

Applies to associated medication in chunk 37

PLENVU

Covered when ALL of the following are met

Two alternative bowel preps: Previous trial on at TWO of the following: Suprep, Clenpiq, Sodium/Potas Sol Magnesium (Suprep), Sutab, Suflav2

Required before PLENVU

Azelastine-fluticasone / Olopatadine HCl 0.6% solution

Covered when ALL of the following are met

Azelastine trial: Previous trial on: azelastine nasal spray

Applies to azelastine-fluticasone and olopatadine 0.6% solution

RASUVO / IVERMECTIN 1% cream

Covered when ALL of the following are met

Topical azelaic acid or metronidazole: Previous trial on at least ONE of the following: azelaic acid (topical) or metronidazole (topical)1

Plus prior trial on at least one listed statin

Statin trial: Previous trial on at least ONE of the following: atorvastatin, fluvastatin IR, lovastatin, pravastatin, rosuvastatin, simvastatin1

Both conditions required for IVERMECTIN 1% CREAM

Lisdexamfetamine and methylphenidate

Covered when ALL of the following are met (unless exception applies)

Prior stimulant trial: For lisdexamfetamine and methylphenidate patches: Previous trial on ONE of the following: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, or methylphenidate (capsules/tablets). Step not required for diagnosis of binge-eating disorder.1

Applies to lisdexamfetamine and methylphenidate products

Provider Actions, Documentation & Denial Risk

Prior Authorization

Antiepileptic agents — prior trials required

Antiepileptic agents — prior trials required. Prior authorization for listed agents (e.g., Briviact, Spritam, perampanel, eslicarbazepine, oxcarbazepine ER) requires documentation of previous trials of at least TWO alternative antiepileptic agents (examples: carbamazepine, divalproex, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine IR, phenytoin, tiagabine, topiramate, valproic acid, zonisamide). Failure to document two prior trials may result in denial.

Provider must document trials (medication name, dose, dates, reason for discontinuation) of at least two listed alternatives.
If documentation of two prior trials is absent, prior authorization is not supported.

Prior Authorization

Antidepressant agents — prior trials required

Antidepressant agents — prior trials required. Prior authorization for listed antidepressant/related products (e.g., Aplenzin, Auvelity, Drizalma, EMSAM, Fetzima, Trintellix, venlafaxine ER) requires documentation of previous trials of at least TWO alternate antidepressants from the listed first-line options (bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, venlafaxine except low-dose 12.5 mg).

Document two prior trials with dates, doses, and reason for discontinuation.
If two prior trials are not documented, coverage may be denied.

Prior Authorization

Combination antihypertensive/lipid agent — prior trials required

Combination antihypertensive/lipid agent — prior trials required. Prior authorization for amlodipine-atorvastatin requires documentation of a prior trial on an allowed statin (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin) AND a prior trial on amlodipine.

Provider must submit evidence of prior statin therapy (medication, dose, dates) and prior amlodipine trial.
Absence of documented prior statin and amlodipine trials may lead to denial.

Step Therapy

Dapsone 5% gel step therapy

Dapsone 5% gel — sequential step therapy required. Prior authorization for dapsone 5% gel requires documentation of prior topical therapies per the policy (examples include prior use of topical clindamycin and topical erythromycin, prior trial of tacrolimus, and at least one listed topical steroid depending on clinical context).

Document prior use of topical antibiotics (e.g., clindamycin, erythromycin), topical tacrolimus where applicable, and topical steroid trials with dates/doses and reasons for discontinuation.
If prior sequential therapies are missing or not documented, authorization may be denied.

Step Therapy

DIFICID step therapy

DIFICID (fidaxomicin) — step therapy required. Prior authorization requires documentation of prior trial of oral vancomycin. Additionally, for some clinical pathways, documentation of trials on an ARB/ARB-combination was referenced in source content — ensure relevant prior therapies are documented if applicable to the member’s regimen.

Provide records showing a prior adequate trial of oral vancomycin (dose, dates, response).
If required ARB/combo documentation is applicable, include those prior medication trials.
Absence of documented prior vancomycin trial may result in denial.

Step Therapy

EQUETRO step therapy

EQUETRO — prior trial required. Prior authorization for EQUETRO requires documentation of a prior trial of generic carbamazepine (extended-release or immediate-release).

Document prior trial of generic carbamazepine ER or IR (dose, dates, clinical response).
Lack of evidence of a prior carbamazepine trial may lead to denial.

Step Therapy

FEMRING step therapy

FEMRING — prior topical estrogen trial required. Prior authorization for FEMRING requires documentation of a previous trial on estradiol cream or other designated vaginal estrogen therapy.

Submit documentation of prior topical estradiol therapy (product, dose, dates, reason for change).
If prior vaginal estrogen trial is not documented, coverage may be denied.

Step Therapy

GEMTESA step therapy

GEMTESA — step therapy required. Prior authorization for GEMTESA requires documentation that the patient has tried Myrbetriq (mirabegron) and at least one antimuscarinic agent from solifenacin, darifenacin, or fesoterodine.

Provide records of prior trials: Myrbetriq (mirabegron) plus one of solifenacin, darifenacin, or fesoterodine (dates/doses/reason for discontinuation).
Absence of these documented trials may result in denial.

Step Therapy

INCRUSE step therapy

INCRUSE ELLIPTA — prior trial required. Prior authorization requires documentation that the patient tried tiotropium (Spiriva) before coverage of INCRUSE.

Document prior Spiriva (tiotropium) use with dates and response.
If no documented Spiriva trial exists, prior authorization may be denied.

Step Therapy

PLENVU step therapy

PLENVU — step therapy required. Prior authorization requires documentation of prior trials on at least TWO alternative bowel preparation agents (examples: Suprep, Clenpiq, Sutab, others listed).

Provide documentation of two prior adequate bowel prep trials (agent names, dates).
If two prior alternatives are not documented, coverage may be denied.

Step Therapy

Clindamycin-BPO gel step therapy

Clindamycin-BPO gel products — prior use required. Prior authorization for listed clindamycin-BPO gels requires documentation of prior use of clindamycin-BPO 1.2%-5%.

Document prior use of clindamycin-BPO 1.2%-5% (product, concentration, dates).
Absence of this prior use may result in denial.

Step Therapy

Azelastine-fluticasone / Olopatadine step therapy

Azelastine–fluticasone and olopatadine nasal solution — prior trial required. Prior authorization requires documentation of a prior trial of azelastine nasal spray before these combination products will be approved.

Provide documentation of prior azelastine nasal spray use (dates/dose/clinical response).
If prior azelastine spray trial is not shown, authorization may be denied.

Step Therapy

RYTARY step therapy

RYTARY — prior trial required. Prior authorization requires documentation that the patient tried generic carbidopa/levodopa before coverage of RYTARY.

Document prior generic carbidopa/levodopa trial (product, dose, dates).
Lack of prior generic carbidopa/levodopa documentation may result in denial.

Step Therapy

QELBREE step therapy

QELBREE — prior trials required. Prior authorization for QELBREE requires documentation that the patient has tried atomoxetine and one of guanfacine or clonidine.

Provide documentation of trials (atomoxetine and guanfacine or clonidine) including dates and reasons for discontinuation.
If required prior agents are not documented, coverage may be denied.

Step Therapy

RASUVO step therapy

RASUVO — prior methotrexate trial required. Prior authorization for RASUVO requires documentation of a prior trial of generic methotrexate.

Document prior generic methotrexate therapy (dose, dates, clinical response).
Absence of documented methotrexate trial may lead to denial.

Step Therapy

Ivermectin cream step therapy

Ivermectin 1% cream — step therapy required. Prior authorization requires documentation of at least ONE prior topical azelaic acid or topical metronidazole trial AND documentation of at least ONE prior statin (atorvastatin, fluvastatin IR, lovastatin, pravastatin, rosuvastatin, simvastatin) where indicated by the policy.

Provide documentation of prior topical azelaic acid or metronidazole use (product, dates) and prior statin therapy when applicable.
Failure to document these prior therapies may result in denial.

Step Therapy Summary Table

Step requirement	Prior medication(s) required
Topical acne trial
Documentation requirement

Step requirement	Prior medication(s) required
Antiepileptic step
Documentation requirement

Step requirement	Prior medication(s) required
Antidepressant step
Documentation requirement

Step requirement	Prior medication(s) required
Corlanor (ivabradine) step
Documentation requirement

Step requirement	Prior medication(s) required
Dapsone 5% gel step
Documentation requirement

Step requirement	Prior medication(s) required
Antidiabetic combination step
Documentation requirement

Step requirement	Prior medication(s) required
DIFICID step
Documentation requirement

Step requirement	Prior medication(s) required
Tacrolimus extended-release step
Documentation requirement

Step requirement	Prior medication(s) required
EQUETRO step
Documentation requirement

Step requirement	Prior medication(s) required
FEMRING step
Documentation requirement

Step requirement	Prior medication(s) required
GEMTESA step
Documentation requirement

Step requirement	Prior medication(s) required
INCRUSE step
Documentation requirement

Step requirement	Prior medication(s) required
Intranasal steroid step
Documentation requirement

Step requirement	Prior medication(s) required
PLENVU step
Documentation requirement

Step requirement	Prior medication(s) required
Clindamycin-BPO gels step
Documentation requirement

Step requirement	Prior medication(s) required
Azelastine-fluticasone / Olopatadine step
Documentation requirement

Step requirement	Prior medication(s) required
RYTARY step
Documentation requirement

Step requirement	Prior medication(s) required
Pramipexole ER step
Documentation requirement

Step requirement	Prior medication(s) required
QELBREE step
Documentation requirement

Step requirement	Prior medication(s) required
RASUVO step
Documentation requirement

Step requirement	Prior medication(s) required
IVERMECTIN 1% cream step
Documentation requirement

Step requirement	Prior medication(s) required
Stimulant trial (lisdexamfetamine / methylphenidate)
Documentation requirement

Step requirement	Prior medication(s) required
SUNOSI listing
Documentation requirement

Step requirement	Prior medication(s) required
Stimulant prior alternatives (general)
Documentation requirement

Step requirement	Prior medication(s) required
SUNOSI prior trial
Documentation requirement

Step requirement	Prior medication(s) required
SYMLINPEN step
Documentation requirement

Step requirement	Prior medication(s) required
Tazarotene 0.05% step
Documentation requirement

Step requirement	Prior medication(s) required
Migraine agents step
Documentation requirement

Step requirement	Prior medication(s) required
PRUCALOPRIDE step
Documentation requirement

Step requirement	Prior medication(s) required
VTAMA step
Documentation requirement

Step requirement	Prior medication(s) required
Ophthalmic prostaglandin step
Documentation requirement

Step requirement	Prior medication(s) required
Vaginal estrogen step
Documentation requirement

Step requirement	Prior medication(s) required
ZORYVE combined-step
Documentation requirement

Policy Summary

PayerSelectHealth

PolicySelectHealth step therapy list (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument prior trials of the specified alternative medications when requesting authorization.

SourceLink

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