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.” All drugs on the step therapy list require prior approval.

We provide quarterly updates to our step therapy drug list.

• To submit a request for drugs provided under a medical benefit and managed by Carelon Medical Benefits Management, access the Carelon portal.
• View the current list of non-oncology drugs [pdf] provided under medical benefit and part of step therapy protocols.
• To view the current list of drugs provided under pharmacy benefit, refer to the member formularies managed by CVS Caremark.

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.

Submission Process under Medical Benefit

Standard step therapy requests should be submitted through the normal prior approval process. 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.

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 FEP or self-insured groups (including but not limited to Walmart, Tyson or other BlueAdvantage groups).

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.