EDIT - Step Therapy

The Step Therapy edit, or prerequisite therapy, is designed to ensure a specific drug is tried by the member before one that is more expensive drug.  The Step Therapy edit is flexible in its use.  The edit allows specific drugs to be mandatory.  It can also require multiple drugs to be used before being allowed to get the next level of drug.

If the claim is a compound, the Step Therapy edit is bypassed.

The following fields are available on the edit.

• Edit Name:  This is the name of the entire EDIT.  This is required.  You have 30 alpha numeric characters.  The Edit Name cannot be duplicated.
• Look back Start:  The number of days from the date of service the safety edit will check the member utilization.
• Look Back End:  The number of days from the date of service the safety edit will check the member utilization.
• Message Group:  This is an optional drop down where you would select an established Message Group.
• Mandatory:  This check box indicates that a drug in the associated Criteria must meet the rules in this step as part of the requirements.  For instance, if marked Mandatory for Criteria representing all Aspirin, for the Step Therapy to be satisfied, Aspiring must be a filled prescription in the Member’s history.
• Step Name:  This is a User entered description to better understand the associated rule.
• Criteria:  This is to select the criteria that is already established.  This criteria will identify the drug or drugs that
• Age Minimum:  What is the minimum age to qualify for the edit.
• Age Maximum: What is the maximum age to qualify for the edit.
• Day Supply Minimum:  What is the minimum days supply of a claim in history meeting the Criteria to qualify for the edit.
• Day Supply Maximum:  What is the maximum days supply of a claim in history meeting the Criteria to qualify for the edit.
• + Add Another Step :  The +Add Another Step allows you to build multiple Step rules within an edit.  
• Steps To Be Fulfilled :  This indicates the number of step rules within the Criteria are requires to pass before the claim can continue to process.

Once the edit has been created, you can either cancel or Save Draft and Review.  If you cancel the edit, you will lose your work.  If you Save Draft and Review you will be presented with the next step where you have the option to CLOSE or ACTIVATE.  If you close the edit, it will be saved and available in Draft state.  If you activate the edit, it will be saved, locked and ready to use in production.

Step Therapy Program Example

When a claim is submitted with an NDC 53746010901 (Hydrocodone/Apap), the claim evaluates through the Member’s claim history.

Before a Member can have a claim for Hydrocodone/Apap (as defined by a Criteria where GPI-08 = 65991702), the member must have tried Ibuprofen for at least 5 days and either Aspirin or Naproxen Sodium.

Below is a Step Therapy Edit for Hydrocodone/Apap.  Based on the edit:

• Aspirin step rule:  Member having one claim of 3 days supply or more at least 5 days before the date of service on this claim.
• Ibuprofen step rule:  Member must have tried Ibuprofen (Mandatory is checked) one claim of at least 5 days supply with a drug in the criteria Ibuprofen All Forms.
• Naproxen Sodium step rule:  Member having one claim of 5 days supply or more at least 5 days before the date of service on this claim.
• 2 of the 3 drugs must be tried before allowing Hydrocodone/Apap.  One of these is mandated to be Ibuprofen.

ASSUMPTION: 

• All drugs that are processing against the Step Therapy Rule are already considered covered.
• Examples are NOT Compounds.  Compounds automatically bypass any step therapy EDIT.