Prior approval information for step therapy protocol exception

Background

In 2021, the Arkansas legislature passed Act 97 requiring an exception request process for drugs identified by the health plan as subject to step therapy. The act defines step therapy protocol as “a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition and that are medically appropriate for a patient are covered by a healthcare insurer or health benefit plan.”

Step therapy drugs can be identified by coverage policy. Any step therapy drug will have the following statement in the applicable coverage policy.

"The Step Therapy Medication Act is applicable to fully-insured (Arkansas Blue Cross, Health Advantage, and Exchange) and specified governmental (ASE/PSE and ASP) health plans. The law is not applicable to FEP or self-insured ERISA groups (including but not limited to Walmart or other Blue Advantage groups). Initial approval for exigent request is 28 days. Otherwise, initial approval for standard review is up to [subject to specific coverage policy].”

Providers can access our coverage policies by clicking here.

Submission Process under Medical Benefit

Under the medical benefit, requests for step therapy drugs can be submitted in the same manner as other medical benefit drugs.

For instructions related to medical oncology drugs that require step therapy, please see Medical Oncology Drugs.

All other standard step therapy requests should be submitted through the normal prior authorization process [pdf].The provider should select “Medical Benefit Drug” as the authorization type for all medical benefit drugs. A response will be provided within 72 business hours of receiving the request. Re-reviews and extended duration requests are permitted for standard requests.

To submit a exigent step therapy protocol exception for drugs under the medical benefit, complete the Exigent Step Therapy Exception request form [pdf]. Please fill out form completely. If any information is missing, it could result in a denial. If the form is submitted to wrong email address or fax number, the request will be denied. Once complete, you can submit the form by either:

• Email to [email protected]
• Fax to 501-301-1960

Approved exigent step therapy exception requests will be allowed only for a duration of up to 28 days. Further approval will require a standard step therapy request as referenced above.

Prescription Drugs - Step Therapy Exceptions

Step Therapy exceptions on the prescription drug benefit are handled by CVS Caremark. This exception review process is set up for fully insured Arkansas Blue Cross and Blue Shield and Health Advantage business as well as select Blue Advantage groups who utilize our prescription drug benefit. To start the process, CVS Caremark can be reached by phone at 877-433-2973 or by fax at 888-487-9257. If the prescription drug benefit is handled by another entity, please review the membership card for contact information.

• To view the current list of drugs provided under pharmacy benefit, refer to the member formularies managed by CVS Caremark.

Applicability

The law is applicable only to our fully insured (Arkansas Blue Cross and Health Advantage) and specified governmental (ASE/PSE and ASP) health plans. The law is not applicable to Medicare Supplement, Medicare Advantage, Access only, AR Health (where Medicare is primary), FEP or self-insured groups (including but not limited to Walmart or other BlueAdvantage groups). Any group that utilizes a prescription drug program vendor (i.e., Arkansas State Employees and Public School Employees, Arkansas State Police and Arkansas State University) may have a different submission process dependent on the requested drug. Please refer to plan websites for additional information.

The law is applicable only to those drugs identified as “step therapy.” Requests for drugs not on the step therapy list will be denied. Providers may submit an exception request for non-step therapy drugs as per usual process of drug/service requests.