CurrentIndependent HealthPolicy N/A

Child Health Plus formulary step therapy protocols (Independent Health)

Step therapy protocols for medications on Independent Health's 2025 Child Health Plus formulary; specifies products affected and the pharmacy-history-based criteria that trigger online step checks and when prior authorization is required.

Policy Summary

PayerIndependent Health

PolicyChild Health Plus formulary step therapy protocols (Independent Health)

Policy CodePolicy N/A

Change Typeclarified

Effective Date12/1/2025

Next Review Date

Key ActionIf the patient's Independent Health pharmacy history does not document the product-specific prior medication or diagnosis within the stated lookback period, the prescription requires prior authorization (online step check triggers PA).

SourceLink

POLICY UPDATE CHANGES

Lists step therapy protocols current as of 12/1/2025 for Independent Health's 2025 Child Health Plus formulary.

~45Listed products with step criteria

120 daysCommon lookback window (most frequent)

90-365 daysRange of lookback windows across products

noMaterial change?

What changed — summary

Independent Health uses pharmacy-history-based Step Therapy (ST) on its 2025 Child Health Plus formulary to require prior trials of certain medications (often generics or lower-cost alternatives) before covering more costly or brand medications. Pharmacy profile checks trigger online step routing and a prior authorization is required when the patient's Independent Health prescription history does not meet the product-specific criterion. This document compiles the product-specific pharmacy-history-based criteria and lookback windows and lists step therapy protocols current as of 12/1/2025 for Independent Health's 2025 Child Health Plus formulary.

Step therapy thresholds & summary metrics

Listed products with step criteria~45 products on Child Health Plus formulary

Common lookback window (most frequent)filled within previous 120 days

Range of lookback windows across products90–365 days (examples: 90, 120, 130, 180, 365)

Example: Airsupra requirementinhaled corticosteroid filled within previous 120 days

Example: GLP‑1 requirementtype 2 diabetes diagnosis OR oral antidiabetic (excluding metformin) filled within past 130 days

Example: Eucrisa requirementtopical corticosteroid or topical calcineurin inhibitor filled within previous 365 days

Key actionCheck formulary Notes for 'ST' and the patient's Independent Health pharmacy profile before dispensing

Step therapy criteria (pharmacy-history based)

General Step Therapy Rule

Medications designated with 'ST' require prior trial(s) as documented in the patient's Independent Health pharmacy history; if the pharmacy profile does not meet the criterion, prior authorization is required.

Thresholds (name = requirement)

Airsupra prior inhaled corticosteroid fill windowfilled within previous 120 days

GLP-1 (antidiabetic) trial windowtype 2 diabetes diagnosis OR any oral antidiabetic (excluding metformin) filled within past 130 days

Entacapone concurrent useconcurrent use of carbidopa/levodopa documented

Desonide prior therapy windowalclometasone filled within previous 90 days

Aprepitant prior steroid trialat least a five-day supply of dexamethasone filled within previous 90 days

Eucrisa prior topical therapy windowtopical corticosteroid or topical calcineurin inhibitor filled within previous 365 days

Granisetron prior ondansetron windowondansetron filled within previous 180 days

Opioid/narcotic prior use windownarcotic medications filled within previous 120 days

Aliskiren ACE + ARB prior fill windowACE inhibitor AND ARB filled within previous 90 days

Serevent concurrent therapyconcurrent use of an inhaled corticosteroid or Spiriva documented

Tramadol ER prior IR trialimmediate‑release tramadol filled within previous 90 days

Ubrelvy prior triptan windowgeneric triptan product filled within previous 120 days

Uloric prior allopurinol windowallopurinol filled within previous 90 days

Most frequent lookback120 days

Listed products (drug names and strengths)

Listed products (drug names and strengths as indexed)NDC|mixed

Airsupra AEROSOL 90-80 MCG/ACT INHALATION	Airsupra inhalation product (step criterion: prior inhaled corticosteroid within 120 days)
MOUNJARO SOLUTION AUTO-INJECTOR 10 MG/0.5ML SUBCUTANEOUS	GLP-1 product
MOUNJARO SOLUTION AUTO-INJECTOR 12.5 MG/0.5ML SUBCUTANEOUS	GLP-1 product
MOUNJARO SOLUTION AUTO-INJECTOR 15 MG/0.5ML SUBCUTANEOUS	GLP-1 product
MOUNJARO SOLUTION AUTO-INJECTOR 2.5 MG/0.5ML SUBCUTANEOUS	GLP-1 product
MOUNJARO SOLUTION AUTO-INJECTOR 5 MG/0.5ML SUBCUTANEOUS	GLP-1 product
MOUNJARO SOLUTION AUTO-INJECTOR 7.5 MG/0.5ML SUBCUTANEOUS	GLP-1 product
OZEMPIC (0.25 OR 0.5 MG/DOSE) SOLUTION PEN-INJECTOR 2 MG/3ML SUBCUTANEOUS	GLP-1 product
OZEMPIC (1 MG/DOSE) SOLUTION PEN-INJECTOR 4 MG/3ML SUBCUTANEOUS	GLP-1 product
OZEMPIC (2 MG/DOSE) SOLUTION PEN-INJECTOR 8 MG/3ML SUBCUTANEOUS	GLP-1 product

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What prescribers & pharmacies must do

Prior Authorization

Prior authorization when pharmacy profile does not meet criterion

If the patient's Independent Health pharmacy history does not document the product-specific prior medication or diagnosis within the stated lookback period, the prescription requires prior authorization (online step check triggers PA).

Online step check triggers PA

Documentation Required

Pharmacy history documentation required

Prescribers/dispensing pharmacies should ensure that prior fills or concurrent therapies are present in the Independent Health prescription history to avoid prior authorization requirements.

Ensure prior fills or concurrent therapies are present in Independent Health prescription history.

Billing Rule

Formulary "ST" designation

Medications requiring step therapy are designated with 'ST' in the formulary Notes column; check formulary notes when processing claims.

Check formulary Notes column for "ST" when processing claims.

Definitions and contact

Definition: ST = Step Therapy designation in the formulary Notes indicating the product has an associated step protocol.

Who to contact with questions: Member Services at (716) 250-7183 or 1-833-891-9372, Monday–Friday 8 a.m.–8 p.m.; TTY 711.

Document changes

2025-12-01clarifiedLatest