CurrentSelectHealthPolicy N/A

Medications Subject to Step Therapy — Pharmacy Coverage Criteria

Lists medications subject to step therapy and the specific prior-treatment requirements members must meet before coverage is approved; affects providers and pharmacists submitting prior authorization requests.

Policy Summary

PayerSelectHealth

PolicyMedications Subject to Step Therapy — Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide prior trial documentation of the specified alternative agent(s) listed for the medication to support prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+distinct medication groups listed

Mostrequire prior trial

20+medications listed in section

1pending CMS approval noted

Coverage Criteria for Specified Medications

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.

Topical acne combination products (e.g., adapalene-benzoyl peroxide, tretinoin microspere formulations)

Covered when ALL of the following are met:

Topical acne step: Previous trial on at least ONE generic topical acne treatment

Adapalene and tazarotene products

Covered when ALL of the following are met:

Non-micronized tretinoin step: Previous use of non-micronized tretinoin

Selected anticonvulsant and psychiatric medications

Covered when ALL of the following are met:

Prior antipsychotic/anticonvulsant trial: Previous trial on at least ONE of the following: aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone

Includes multiple listed neurologic agents.

Belsomra (suvorexant)

Covered when ALL of the following are met:

Prior hypnotic trial: Previous trial on at least ONE of the following: zolpidem IR, zolpidem ER, zaleplon, eszopiclone, temazepam, triazolam, ramelteon, trazodone

Bevespi Aerosphere (COPD inhaler)

Covered when ALL of the following are met:

LAMA/LABA requirement: Patient must try BOTH Anoro and Stiolto

Also lists previous trial of mesalamine separately in the source.

Amlodipine-atorvastatin combination

Covered when ALL of the following are met:

Statin and amlodipine trial: Previous trial on at least ONE of the following statins: atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin AND previous trial on amlodipine

Certain tricyclic antidepressants

Covered when ALL of the following are met:

TCA alternative trial: Previous trial on at least ONE of the following: amitriptyline, amoxapine, desipramine, doxepin, imipramine, nortriptyline

Applies to clomipramine, protriptyline, trimipramine.

Ivabradine

Covered when ALL of the following are met except where noted:

Beta-blocker trial: Previous trial on at least ONE of the following: acebutolol, atenolol, bisoprolol, labetalol, metoprolol, nadolol, pindolol, propranolol, timolol

Exception for dilated cardiomyopathy in pediatric patients.

Dapsone 5% gel

Covered when ALL of the following are met:

Topical antibiotic and immunomodulator/corticosteroid trials: Previous use of topical clindamycin AND topical erythromycin; previous trial on tacrolimus; AND previous trial on at least ONE of: betamethasone, clobetasol, hydrocortisone, triamcinolone

Fidaxomicin (Dificid)

Covered when ALL of the following are met:

Vancomycin trial: Patient has tried oral vancomycin

DIFICID initial step therapy criteria