CurrentIndependent HealthPolicy N/A

Step therapy criteria for Child Health Plus formulary medications

Defines step therapy requirements for prescription medications on Independent Health's 2026 Child Health Plus formulary and explains when prior authorization is required based on the member's pharmacy history. Applies to providers and pharmacies processing prescriptions for members covered under this formulary.

Policy Summary

PayerIndependent Health

PolicyStep therapy criteria for Child Health Plus formulary medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionConfirm the member's pharmacy history documents the specified prior fill or concurrent medication to route the prescription online; otherwise submit prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple productsproducts with ST

90–365 dayslookback range

120 dayscommon prior-fill window

3distinct step/PA entries

Coverage Criteria by Product

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GLP-1 agents

Antidiabetic GLP-1 medications

GLP-1 approval: Prescription processes online if pharmacy history documents type 2 diabetes OR trial of any oral antidiabetic drug (excluding metformin) within the past 130 days130 days

If not documented, prior authorization required

Entacapone

Entacapone 200 mg

Entacapone approval: Online if pharmacy history documents concurrent use of carbidopa/levodopaconcurrent use

If not documented, prior authorization required

Desonide

Desonide 0.05% external

Desonide approval: Online if pharmacy history documents alclometasone fill within previous 90 days90 days

If not documented, prior authorization required

Aprepitant

Aprepitant capsules and packs

Aprepitant approval: Online if pharmacy history documents at least a five day supply of dexamethasone filled within the previous 90 days90 days and >=5 day supply

If not documented, prior authorization required

Eucrisa

Eucrisa ointment 2%

Eucrisa approval: Online if pharmacy history documents prior use of a topical corticosteroid or topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) within the previous 365 days365 days

If not documented, prior authorization required

Granisetron

Granisetron 1 mg tablet

Granisetron approval: Online if pharmacy history documents ondansetron fill within previous 180 days180 days

If not documented, prior authorization required

Opioid-related products

Opioid escalation products (fentanyl patches, hydrocodone ER, listed opioids)

Opioid/strong opioid approval: Online if pharmacy history documents narcotic medication fills within the previous 120 days120 days

If not documented, prior authorization required

Aliskiren

Aliskiren 150 mg and 300 mg

Aliskiren approval: Online if pharmacy history documents fills for an ACE inhibitor AND an ARB within previous 90 days90 days

If not documented, prior authorization required

Serevent Diskus

Serevent approval: Online if pharmacy history documents concurrent use of an inhaled corticosteroid or Spirivaconcurrent use

If not documented, prior authorization required

Ubrelvy

Ubrelvy (ubrogepant)

Ubrelvy approval: Online if pharmacy history documents a generic triptan fill within the previous 120 days120 days

If not documented, prior authorization required

Initial Step Therapy / Prior Authorization Conditions

Covered when pharmacy profile shows required prior therapy or concurrent medication; otherwise prior authorization required

Inhaled product concurrency: A prescription is routed online if the patient's Independent Health prescription history documents concurrent use of an inhaled corticosteroid or Spiriva; if not, prior authorization is required.concurrent use documented

If not documented, prior authorization required

Ubrelvy prior triptan: A prescription for Ubrelvy is routed online if the patient's Independent Health prescription history documents that a generic triptan was filled within the previous 120 days; otherwise prior authorization is required.generic triptan fill within 120 days

If not documented, prior authorization required

Uloric prior allopurinol: A prescription for febuxostat (Uloric) is routed online if the patient's Independent Health prescription history documents that allopurinol was filled within the previous 90 days; otherwise prior authorization is required.allopurinol fill within 90 days

If not documented, prior authorization required

Affected Products and Lookback Windows

Products Affected - UbrelvyNDC|proprietaryCovered

UBRELVY TABLET 50 MG ORAL	UBRELVY TABLET 50 MG ORAL
UBRELVY TABLET 100 MG ORAL	UBRELVY TABLET 100 MG ORAL

Products Affected - UloricNDC|proprietaryCovered

febuxostat tablet 40 mg oral	febuxostat tablet 40 mg oral
febuxostat tablet 80 mg oral	febuxostat tablet 80 mg oral

GLP-1 prior therapy lookback — 130 days

Lookback window130 days

Applies toAntidiabetic GLP-1 medications

Online processing conditionPharmacy history documents type 2 diabetes OR trial of any oral antidiabetic (excluding metformin) within prior 130 days

Topical steroid/calcineurin lookback for Eucrisa — 365 days

Lookback window90 days

Applies toDesonide 0.05% external (alclometasone prerequisite)

Online processing conditionPharmacy history documents an alclometasone fill within the previous 90 days

Ondansetron lookback for granisetron — 180 days

Lookback window180 days

Applies toGranisetron 1 mg tablet (ondansetron prerequisite)

Online processing conditionPharmacy history documents an ondansetron fill within the previous 180 days

Dexamethasone lookback for aprepitant — 90 days

Lookback window90 days

Applies toAprepitant capsules and packs

Online processing conditionPharmacy history documents at least a five‑day supply of dexamethasone filled within the previous 90 days

Narcotic/triptan lookback — 120 days

Lookback window120 days

Applies toSpecified narcotic escalation products (fentanyl patches, hydrocodone ER, listed opioids)

Online processing conditionPharmacy history documents narcotic medication fills within the previous 120 days

ACE + ARB lookback for aliskiren — 90 days

Lookback window90 days

Applies toAliskiren 150 mg and 300 mg

Online processing conditionPharmacy history documents fills for an ACE inhibitor AND an ARB within the previous 90 days

Ubrelvy triptan lookback — 120 days

Lookback window120 days

Applies toUbrelvy (ubrogepant) — UBRELVY TABLET 50 MG ORAL; UBRELVY TABLET 100 MG ORAL

Online processing conditionPharmacy history documents a generic triptan fill (e.g., sumatriptan, naratriptan, rizatriptan) within the previous 120 days

Uloric allopurinol lookback — 90 days

Lookback window90 days

Applies toUloric (febuxostat) — febuxostat tablet 40 mg; febuxostat tablet 80 mg

Online processing conditionPharmacy history documents an allopurinol fill within the previous 90 days

Prior Authorization & Documentation Requirements

Prior Authorization

GLP-1 prior authorization — Step / documentation check

A prescription for an antidiabetic GLP-1 medication will process through online routing if the patient's Independent Health prescription history documents either a diagnosis of type 2 diabetes or a fill for any oral antidiabetic drug (excluding metformin) within the past 130 days. If the pharmacy profile does not document one of these, prior authorization is required.

Trigger window: prior oral antidiabetic (non-metformin) fill within 130 days
Documentation accepted: Independent Health pharmacy/prescription history or prescriber documentation supporting type 2 diabetes diagnosis
Action if unmet: submit prior authorization

Prior Authorization

Entacapone prior authorization — Concomitant therapy required

A prescription for entacapone (200 mg) will route online if the patient's Independent Health prescription history documents concurrent use of carbidopa/levodopa. If the pharmacy profile does not document concurrent carbidopa/levodopa, prior authorization is required.

Required concurrency: carbidopa/levodopa on pharmacy profile
Action if unmet: submit prior authorization documenting rationale or evidence of carbidopa/levodopa use

Prior Authorization

Aprepitant prior authorization — Corticosteroid prerequisite

A prescription for aprepitant (including the 80 & 125 mg capsule therapy pack and EMEND suspension) will route online if the patient's Independent Health prescription history documents at least a five-day supply of dexamethasone filled within the previous 90 days. Prior authorization is required if this is not documented on the pharmacy profile.

Required prior fill: dexamethasone (>= 5 day supply) within 90 days
Products noted: aprepitant capsule therapy pack 80 & 125 mg, EMEND suspension 125 mg/5 mL
Action if unmet: submit prior authorization with supporting clinical rationale

Prior Authorization

Eucrisa prior authorization — Prior topical therapy required

A prescription for Eucrisa (crisaborole) will route online if the patient's Independent Health prescription history documents prior use of a topical corticosteroid or a topical calcineurin inhibitor (for example, pimecrolimus or tacrolimus) within the previous 365 days. Prior authorization is required when the pharmacy profile does not document this prior therapy.

Required prior therapy: topical corticosteroid or topical calcineurin inhibitor within 365 days
Action if unmet: submit prior authorization with documentation of prior therapies or medical necessity

Prior Authorization

Granisetron prior authorization — Triggers from ondansetron history

A prescription for granisetron 1 mg tablet will route online if the patient's Independent Health prescription history documents ondansetron filled within the previous 180 days. Prior authorization is required when the pharmacy profile does not document an ondansetron fill in that timeframe.

Required prior fill: ondansetron within 180 days
Action if unmet: submit prior authorization documenting prior antiemetic therapy or clinical need

Prior Authorization

Opioid escalation prior authorization — Recent narcotic fill required

A prescription for specified extended-release opioid products (including listed morphine ER and oxymorphone ER strengths) will route online if the patient's Independent Health prescription history documents a narcotic medication fill within the previous 120 days. Prior authorization is required when the pharmacy profile does not show a narcotic fill in that period.

Affected products include certain morphine sulfate ER and oxymorphone ER formulations (see formulary for exact NDCs)
Required prior fill window: narcotic medication within 120 days
Action if unmet: submit prior authorization and any supporting documentation

Prior Authorization

Aliskiren prior authorization — Prior ACE inhibitor and ARB required

A prescription for aliskiren (300 mg) will route online if the patient's Independent Health prescription history documents fills for both an ACE inhibitor and an ARB within the previous 90 days. If the pharmacy profile does not document both ACE inhibitor and ARB fills in that timeframe, prior authorization is required.

Required prior fills: ACE inhibitor and ARB within 90 days (examples: lisinopril; losartan)
Action if unmet: submit prior authorization with documentation of prior therapies or clinical rationale

Prior Authorization

Serevent prior authorization — Inhaled corticosteroid / Spiriva concurrency check

A prescription for Serevent Diskus and similar inhaled products will route online if the patient's Independent Health prescription history documents concurrent use of an inhaled corticosteroid or Spiriva. Prior authorization is required when the pharmacy profile does not document the concurrent inhaled corticosteroid or Spiriva.

Required concurrency: inhaled corticosteroid or tiotropium (Spiriva) documented on pharmacy profile
Online routing allowed only when concurrency is present; otherwise prior authorization required

Step Therapy

Ubrelvy prior authorization — Triptan step therapy rule

A prescription for Ubrelvy (ubrogepant) will route online if the patient's Independent Health prescription history documents a fill for a generic triptan (for example, sumatriptan, naratriptan, rizatriptan) within the previous 120 days. If the pharmacy profile does not show a qualifying generic triptan fill in that window, prior authorization is required.

Required prior fill: generic triptan within 120 days (examples: sumatriptan, naratriptan, rizatriptan)
Action if unmet: submit prior authorization documenting prior triptan trial or contraindication

Step Therapy

Uloric prior authorization — Allopurinol step therapy rule

A prescription for febuxostat (Uloric) will route online if the patient's Independent Health prescription history documents a fill of allopurinol within the previous 90 days. Prior authorization is required when the pharmacy profile does not document an allopurinol fill in that timeframe.

Required prior fill: allopurinol within 90 days
Action if unmet: submit prior authorization documenting prior allopurinol trial, intolerance, or contraindication

Policy Background

Step therapy is a formulary management tool used to encourage use of established, typically lower‑cost or preferred medications (for example, generic or first‑line therapies) before coverage is provided for alternative agents. Medications subject to step therapy are identified with an "ST" flag in the formulary Notes column and are governed by product‑specific lookback windows and prior‑fill requirements documented in the member's Independent Health prescription history.

When the pharmacy profile documents the required prior therapy or concurrent medication within the specified lookback period, the prescription will route online for processing. If the pharmacy/prescription history does not meet the stated criterion for a product (for example, evidence of type 2 diabetes or a qualifying oral antidiabetic trial within 130 days for GLP‑1 agents), prior authorization is required before the medication can be approved.

Key Definitions

Step therapy — definition and brief explanation

DefinitionStep therapy requires trying specified preferred or first‑line therapies (often generic) before coverage of another medication for the same condition

Formulary flagMedications requiring step therapy are indicated with 'ST' in the formulary Notes column

Operational ruleMedications flagged 'ST' require pharmacy/prescription history evidence of the specified prior therapy within the defined lookback window to route a prescription online; absent documentation triggers prior authorization

Initial Step Requirements

Ubrelvy initial therapy

Ubrelvy initial step requirement

Triptan trial: Pharmacy history documents a generic triptan fill within the previous 120 days.120 days

If not documented, prior authorization required

Uloric initial therapy

Uloric initial step requirement

Allopurinol trial: Pharmacy history documents an allopurinol fill within the previous 90 days.90 days

If not documented, prior authorization required

Step Therapy Operational Rules

Medication / Category	Step therapy requirement (lookback)	Online routing condition	If not documented
Medications flagged 'ST' on the formulary
Varies by product (see product-specific rows) — lookback windows range from 90 to 365 days
Prescription routes online only when the member's Independent Health pharmacy history documents the specific prior therapy or concurrent medication required for the product
Prior authorization is required when the pharmacy profile does not document the required prior therapy or concurrent medication

Product	Required prior therapy	Lookback window	Coverage action if documented
Ubrelvy (ubrogepant) — UBRELVY TABLET 50 MG ORAL; UBRELVY TABLET 100 MG ORAL
Generic triptan (e.g., sumatriptan, naratriptan, rizatriptan) fill documented in pharmacy history
120 days prior to Ubrelvy prescription
Prescription routes online (no prior authorization required)

Product	Required prior therapy	Lookback window	Coverage action if documented
Uloric (febuxostat) — febuxostat tablet 40 mg oral; febuxostat tablet 80 mg oral
Allopurinol fill documented in pharmacy history
90 days prior to febuxostat prescription
Prescription routes online (no prior authorization required)

Product / class	Required concurrent medication	Documentation required	Coverage action if documented
Inhaled products subject to step therapy (e.g., Serevent Diskus)
Concurrent use of an inhaled corticosteroid OR Spiriva (tiotropium)
Pharmacy profile must document concurrent inhaled corticosteroid or Spiriva use
Prescription routes online (no prior authorization required)

Policy Summary

PayerIndependent Health

PolicyStep therapy criteria for Child Health Plus formulary medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionConfirm the member's pharmacy history documents the specified prior fill or concurrent medication to route the prescription online; otherwise submit prior authorization.

SourceLink

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