II-242-002

Medical Policy:

II-242-002

Topic:

Step Therapy Supplement

Section:

Medicine

Effective Date:

August 3, 2020

Issued Date:

June 28, 2021

Last Revision Date:

May 2020

Annual Review:

June 2021

This policy version was replaced August 1, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Step therapy is a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition, including self-administered and physician-administered drugs, are medically appropriate for a particular enrollee and are eligible for coverage under a health plan.

The intent of the Step Therapy Supplement policy is to provide additional criteria to ensure compliance to MN Statute 62Q.184. This policy will apply if the step therapy component within a medical drug policy is not able to be approved.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Note: This policy applies to commercial lines of business only.

I. The step therapy requirement for a requested agent may be met by ONE of the following:

The patient is currently being treated with the requested agent as indicated by ALL of the following:
- A statement by the prescriber that the patient is currently taking the requested agent; and
- A statement by the prescriber that the patient is currently receiving a positive therapeutic outcome on requested agent; and
- The prescriber states that a change in therapy is expected to be ineffective or cause harm;
OR
The patient’s medication history includes the required prerequisite/preferred agent(s) as indicated by:
- Evidence of a paid claim(s); or
- The prescriber has stated that the patient has tried the required prerequisite/preferred agent(s) AND the required prerequisite/preferred agent(s) was discontinued due to lack of effectiveness or an adverse event
OR
The prescriber has provided documentation that the required prerequisite/preferred agent(s) cannot be used due to a documented medical condition or comorbid condition that is likely to cause an adverse reaction, decrease ability of the patient to achieve or maintain reasonable functional ability in performing daily activities or cause physical or mental harm.

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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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