Step therapy criteria for Child Health Plus formulary medications
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria by Product
GLP-1 agents
Antidiabetic GLP-1 medications
If not documented, prior authorization required
Entacapone
Entacapone 200 mg
If not documented, prior authorization required
Desonide
Desonide 0.05% external
If not documented, prior authorization required
Aprepitant
Aprepitant capsules and packs
If not documented, prior authorization required
Eucrisa
Eucrisa ointment 2%
If not documented, prior authorization required
Granisetron
Granisetron 1 mg tablet
If not documented, prior authorization required
Opioid-related products
Opioid escalation products (fentanyl patches, hydrocodone ER, listed opioids)
If not documented, prior authorization required
Aliskiren
Aliskiren 150 mg and 300 mg
If not documented, prior authorization required
Serevent Diskus
Serevent Diskus
If not documented, prior authorization required
Ubrelvy
Ubrelvy (ubrogepant)
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
If not documented, prior authorization required
If not documented, prior authorization required
If not documented, prior authorization required
Affected Products and Lookback Windows
| UBRELVY TABLET 50 MG ORAL | UBRELVY TABLET 50 MG ORAL |
| UBRELVY TABLET 100 MG ORAL | UBRELVY TABLET 100 MG ORAL |
| febuxostat tablet 40 mg oral | febuxostat tablet 40 mg oral |
| febuxostat tablet 80 mg oral | febuxostat tablet 80 mg oral |
Prior Authorization & Documentation Requirements
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
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
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
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
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
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
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
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
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
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
Initial Step Requirements
Ubrelvy initial therapy
Ubrelvy initial step requirement
If not documented, prior authorization required
Uloric initial therapy
Uloric initial step requirement
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) |
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