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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsViva Health Step Therapy Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentViva Health PlanPolicy N/A

    Step Therapy Criteria

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    This policy governs step therapy requirements for specified prescription drugs under Viva Health Plan's Medicare Advantage pharmacy benefit. Coverage is provided after the member has tried specified generic or lower-cost alternative therapy for at least 30 days, or two alternatives for esomeprazole magnesium.

    Policy Summary
    PayerViva Health Plan
    PolicyStep Therapy Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least a 30-day trial of the required generic or alternative therapy before requesting the nonpreferred drug.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    9Step therapy groups
    30 daysRequired trial duration
    8Groups requiring one alternative
    2 of 3Esomeprazole alternatives

    Covered Drugs and Prerequisite Therapy

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Aripiprazole ODT

    Coverage will be provided when the required prerequisite therapy has been tried.

    Aripiprazole ODT prerequisite: At least a 30-day supply of generic aripiprazole immediate release tablet has been tried.at least 30 days

    Baraclude

    Coverage will be provided when the required prerequisite therapy has been tried.

    Baraclude prerequisite: At least a 30-day supply of generic entecavir tablets has been tried.at least 30 days

    Bisphosphonates

    Coverage will be provided when the required prerequisite therapy has been tried.

    Bisphosphonate prerequisite: At least a 30-day supply of alendronate, ibandronate, or risedronate has been tried.at least 30 days

    Any one listed alternative satisfies the prerequisite.

    Brinzolamide

    Coverage will be provided when the required prerequisite therapy has been tried.

    Brinzolamide prerequisite: At least a 30-day supply of dorzolamide 2% ophthalmic solution has been tried.at least 30 days

    Lamotrigine

    Coverage will be provided when the required prerequisite therapy has been tried.

    Lamotrigine prerequisite: At least a 30-day supply of generic lamotrigine immediate release tablets or generic lamotrigine chewable, dispersible tablets has been tried.at least 30 days

    Either listed formulation satisfies the prerequisite.

    Levalbuterol

    Coverage will be provided when the required prerequisite therapy has been tried.

    Levalbuterol prerequisite: At least a 30-day supply of albuterol HFA has been tried.at least 30 days

    Olanzapine ODT

    Coverage will be provided when the required prerequisite therapy has been tried.

    Olanzapine ODT prerequisite: At least a 30-day supply of generic olanzapine immediate release tablet has been tried.at least 30 days

    PPI / Esomeprazole magnesium

    Coverage will be provided when the required prerequisite therapies have been tried.

    PPI prerequisites

    • Eligible generic alternatives: Omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.

      Two alternatives are required.

    Risperidone ODT

    Coverage will be provided when the required prerequisite therapy has been tried.

    Risperidone ODT prerequisite: At least a 30-day supply of generic risperidone immediate release tablet has been tried.at least 30 days

    Documentation and Coverage Requirements

    Step Therapy

    Aripiprazole ODT Step Therapy

    Before requesting coverage for aripiprazole ODT, document that the member tried a 30-day supply of generic aripiprazole immediate-release tablets.

    • Affected drug: ARIPIPRAZOLE ODT
    Step Therapy

    Baraclude Step Therapy

    Before requesting coverage for Baraclude, document that the member tried a 30-day supply of generic entecavir tablets.

    • Affected drug: BARACLUDE
    Step Therapy

    Bisphosphonate Step Therapy

    Before requesting coverage for the listed bisphosphonate therapy, document that the member tried a 30-day supply of an applicable generic alternative.

    • Applicable alternatives: alendronate, ibandronate, or risedronate
    • Affected drugs: ALENDRONATE SODIUM, RISEDRONATE SODIUM DR
    Step Therapy

    Brinzolamide Step Therapy

    Before requesting coverage for brinzolamide, document that the member tried a 30-day supply of dorzolamide 2% ophthalmic solution.

    • Affected drug: BRINZOLAMIDE
    Step Therapy

    Lamotrigine Step Therapy

    Before requesting coverage for the listed lamotrigine therapy, document that the member tried a 30-day supply of an applicable generic formulation.

    • Alternatives: generic lamotrigine immediate-release tablets or generic lamotrigine chewable, dispersible tablets
    • Affected drugs: LAMOTRIGINE ER, SUBVENITE
    Step Therapy

    Levalbuterol Step Therapy

    Before requesting coverage for levalbuterol tartrate HFA, document that the member tried a 30-day supply of albuterol HFA.

    • Affected drug: LEVALBUTEROL TARTRATE HFA
    Step Therapy

    Olanzapine ODT Step Therapy

    Before requesting coverage for olanzapine ODT, document that the member tried a 30-day supply of generic olanzapine immediate-release tablets.

    • Affected drug: OLANZAPINE ODT

    Unsupported block type: step_therapy підassistant

    Step Therapy

    Risperidone ODT Step Therapy

    Before requesting coverage for risperidone ODT, document that the member tried a 30-day supply of generic risperidone immediate-release tablets.

    • Affected drug: RISPERIDONE ODT
    Step Therapy

    Required Step Therapy

    Step therapy requires documentation of the specified generic or alternative therapy before coverage can be provided. The required therapy must generally be tried for at least a 30-day supply; esomeprazole magnesium requires trials of two listed alternatives.

    • Document the drug name, formulation, and at least 30-day trial for the applicable alternative.
    • For esomeprazole magnesium, document trials of two of: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.
    Denial Risk

    Incomplete Step Therapy May Result in Denial

    Coverage may be denied when the required step-therapy trial is incomplete or cannot be documented. Submit evidence of the applicable trial before requesting coverage for the step-therapy drug.

    • A trial shorter than 30 days may not satisfy the requirement.
    • For esomeprazole magnesium, failure to document trials of two listed alternatives may result in denial.

    Policy Background

    This administrative pharmacy step therapy policy applies to specified prescription drugs under Viva Health Plan’s Medicare Advantage pharmacy benefit. Coverage for a listed nonpreferred drug is provided after the member has tried the required generic or alternative medication for at least a 30-day supply. For esomeprazole magnesium, the member must try two of three specified generic alternatives: omeprazole capsules, pantoprazole tablets, or lansoprazole capsules.

    Initial Coverage Requirements

    Initial therapy requirements

    Initial coverage is provided after the applicable prerequisite therapy has been tried.

    Drug-specific step therapy: For each covered drug group, the specified generic or alternative therapy must have been tried for at least a 30-day supply before coverage is provided.at least 30 days

    For the PPI group, two of three listed generic alternatives are required.

    Required Alternative Therapy by Drug

    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Generic aripiprazole immediate release tabletAripiprazole ODTAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Generic entecavir tabletsBaracludeAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1At least one of: alendronate, ibandronate, or risedronateApplicable bisphosphonate therapyAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Dorzolamide 2% ophthalmic solutionBrinzolamideAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1One of: generic lamotrigine immediate release tablets or generic lamotrigine chewable, dispersible tabletsLamotrigine ER or SubveniteAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Albuterol HFALevalbuterol tartrate HFAAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Generic olanzapine immediate release tabletOlanzapine ODTAt least a 30-day supplyProvided after the prerequisite trial
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Any two of: generic omeprazole capsules, generic pantoprazole tablets, or generic lansoprazole capsulesEsomeprazole magnesiumAt least a 30-day supply of each of two alternativesProvided after the prerequisite trials
    StepRequired prerequisite therapyRequested therapyTrial requirementCoverage
    1Generic risperidone immediate release tabletRisperidone ODTAt least a 30-day supplyProvided after the prerequisite trial
    Policy Summary
    PayerViva Health Plan
    PolicyStep Therapy Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least a 30-day trial of the required generic or alternative therapy before requesting the nonpreferred drug.
    SourceLink
    On This Page
    Covered Drugs and Prerequisite TherapyDocumentation and Coverage RequirementsPolicy BackgroundInitial Coverage RequirementsRequired Alternative Therapy by Drug