CurrentSelectHealthPolicy N/A

Serious Mental Illness Step Therapy Exception Form

This form documents requests for exceptions to step therapy requirements for medications used to treat serious mental illness for SelectHealth members; it is completed by the prescriber and accompanies the exception request process.

Policy Summary

PayerSelectHealth

PolicySerious Mental Illness Step Therapy Exception Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must submit the completed Step Therapy Exception Form with required fields and a signed attestation that one of the statutory criteria for exemption is met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4sections on form

4enumerated exemption criteria

Coverage Criteria for Step Therapy Exception

Step Therapy Exception Criteria

Covered (exception granted) when ANY one of the following statutory criteria is met and attested by the prescriber:

Step therapy exception criteria:

Policy Summary

PayerSelectHealth

PolicySerious Mental Illness Step Therapy Exception Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must submit the completed Step Therapy Exception Form with required fields and a signed attestation that one of the statutory criteria for exemption is met.

SourceLink

On This Page

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One or more of the following statutory criteria (attested by the prescriber): (I) the required prescription drug is contraindicated or will likely cause an adverse reaction or harm to the covered person; (II) the required prescription drug is ineffective based on the known clinical characteristics of the covered person and the known characteristics of the prescription regimen; (III) the covered person previously tried the required prescription drug or another drug in the same pharmacologic class (while under the current or a previous health benefit plan) and discontinued it due to lack of efficacy/effectiveness, diminished effect, or an adverse event; (IV) the covered person is currently stable on the requested prescription (after undergoing step therapy or after previously receiving a step-therapy exception).

What the Prescriber Must Do

Step Therapy

Step Therapy Exception Request Submission

Step therapy exception requests must be submitted by the prescriber using the completed Step Therapy Exception Form. The prescriber must provide all required fields on the form, including patient demographics, insurance information, and full prescriber details (including individual NPI and DEA number if applicable), the requested medication and diagnosis, and any supporting clinical information. Submit the completed form to the plan/medical group using the fax or phone contact provided on the form.

Patient demographics: first/middle/last name, date of birth, state, zip code, phone number, and authorized representative contact if applicable.
Insurance information: primary and secondary insurer names and patient ID numbers.
Prescriber details: prescriber name, specialty, address, state, zip code, individual NPI, DEA number (if applicable), office contact person, phone number, and email address.
Medication and clinical information: medication name(s), diagnosis, rationale for exception, and any prior therapy history or documentation.

Note

Statutory Exemption Grounds

A prescriber may request an exemption from step-therapy when one or more of the statutory grounds apply. The prescriber must attest that at least one of these criteria is met when submitting the form.

The required prescription drug is contraindicated or will likely cause an adverse reaction or harm to the covered person.
The required prescription drug is expected to be ineffective based on the known clinical characteristics of the covered person and the known characteristics of the prescription regimen.
The covered person previously tried the required drug or another drug in the same pharmacologic class while on the current or a prior health benefit plan, and treatment was discontinued due to lack of efficacy, diminished effect, or an adverse event.
The covered person is currently stable on a prescription selected by the prescribing provider for the medical condition after undergoing step therapy or after having received a step-therapy exception.

Documentation Required

Required Form Contents

The completed Step Therapy Exception Form must include specific contents to be considered for review. Incomplete forms may delay or prevent approval.

Patient demographics and contact information.
Primary and secondary insurance names and patient ID numbers.
Full prescriber details including individual NPI and DEA (if applicable), office contact, phone, address, and email.
Requested medication, diagnosis, and clinical justification for the exception.
Documentation of prior therapies and reasons for discontinuation where relevant (e.g., lack of efficacy, adverse events).
Prescriber signature or electronic I.D. verification and date, and city of signing.

Denial Risk

Attestation Requirement and Consequences

The prescriber must sign (or electronically verify) an attestation that one of the statutory criteria listed above applies. Failure to attest that at least one statutory criterion is met may result in denial of the step-therapy exemption request.

Attestation of truth and accuracy of the information provided.
Attestation that one of the criteria in subsections (I)–(IV) has been met to exempt the step-therapy requirement.
Prescriber signature or electronic I.D. verification and date.

Key Definitions

Prescriber attestation — Step‑therapy exception definition

DefinitionA formal prescriber attestation that one of the statutory criteria (contraindication/adverse reaction, likely ineffectiveness, prior failure, or patient stability on current therapy) is met to exempt a patient from step-therapy requirements.

Statutory basisAttestation references subsections (4)(a)(I) to (4)(a)(IV) of § 10-16-145, C.R.S.

Required attestation contentPrescriber must attest that at least one of the four criteria applies: (I) required drug is contraindicated or will likely cause harm; (II) required drug is expected to be ineffective based on known clinical characteristics; (III) patient previously tried required or same-class drug and discontinued due to lack of efficacy or adverse event; (IV) patient is stable on the requested prescription after prior step therapy or prior exception.

Signature requirementPrescriber signature or electronic I.D. verification and date are required on the attestation section.

ScopeUsed to request an exemption from step-therapy requirements for a prescription drug under the member's current or previous health benefit plan.

OpenPayer

Serious Mental Illness Step Therapy Exception Form

Coverage Criteria for Step Therapy Exception

What the Prescriber Must Do

Key Definitions

Background and Purpose