Step therapy criteria for Child Health Plus formulary medications
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Defines step therapy requirements for select prescription medications on Independent Health's 2026 Child Health Plus Formulary and explains when prior authorization is required based on a member's pharmacy history; affects providers and pharmacies submitting claims for members on this formulary.
No material clinical or coverage changes in this revision.
Coverage Criteria
GLP-1 initial therapy
GLP-1 antidiabetic products
If pharmacy profile does not meet this, prior authorization is required.
Entacapone coverage
Entacapone
If not documented, prior authorization required.
Desonide coverage
Desonide
If not documented, prior authorization required.
Aprepitant coverage
Aprepitant
If not documented, prior authorization required.
Eucrisa coverage
Eucrisa
If not documented, prior authorization required.
Granisetron coverage
Granisetron
If not documented, prior authorization required.
Opioid ER/fentanyl coverage
Opioid ER and fentanyl patches
If not documented, prior authorization required.
Aliskiren coverage
Aliskiren
If not documented, prior authorization required.
Serevent coverage
Serevent Diskus
If not documented, prior authorization required.
Ubrelvy coverage
Ubrelvy
If not documented, prior authorization required.
Online processing condition (unnamed medication)
Covered when ALL of the following are met for online processing:
If not met, prior authorization is required
Ubrelvy (ubrogepant) online processing condition
Covered for online processing when ANY of the following is met:
If this is not present, prior authorization is required
Uloric (febuxostat) online processing condition
Covered for online processing when ANY of the following is met:
If this is not present, prior authorization is required
The formulary is maintained by Independent Health and may change at any time. Members and providers will receive notice when changes affecting coverage or utilization management are necessary.
Coding and Lookback Windows
| MOUNJARO SOLUTION AUTO-INJECTOR 10 MG/0.5ML SUBCUTANEOUS | |
| MOUNJARO SOLUTION AUTO-INJECTOR 12.5 MG/0.5ML SUBCUTANEOUS | |
| MOUNJARO SOLUTION AUTO-INJECTOR 15 MG/0.5ML SUBCUTANEOUS | |
| MOUNJARO SOLUTION AUTO-INJECTOR 2.5 MG/0.5ML SUBCUTANEOUS | |
| MOUNJARO SOLUTION AUTO-INJECTOR 5 MG/0.5ML SUBCUTANEOUS | |
| MOUNJARO SOLUTION AUTO-INJECTOR 7.5 MG/0.5ML SUBCUTANEOUS | |
| OZEMPIC (2 MG/DOSE) SOLUTION PEN-INJECTOR 8 MG/3ML SUBCUTANEOUS | |
| OZEMPIC (0.25 OR 0.5 MG/DOSE) SOLUTION PEN-INJECTOR 2 MG/3ML SUBCUTANEOUS | |
| OZEMPIC (1 MG/DOSE) SOLUTION PEN-INJECTOR | |
| TRULICITY SOLUTION AUTO-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS |
| entacapone tablet 200 mg oral |
| desonide lotion 0.05% external |
| aprepitant capsule 125 mg oral | |
| aprepitant capsule 80 mg oral | |
| EMEND SUSPENSION RECONSTITUTED 125 MG/5ML ORAL |
| EUCRISA OINTMENT 2% EXTERNAL |
| granisetron hcl tablet 1 mg oral |
| fentanyl patch 72 hour 12 mcg/hr transdermal | |
| fentanyl patch 72 hour 25 mcg/hr transdermal | |
| fentanyl patch 72 hour 50 mcg/hr transdermal | |
| fentanyl patch 72 hour 75 mcg/hr transdermal | |
| fentanyl patch 72 hour 100 mcg/hr transdermal | |
| hydrocodone bitartrate er tablet 20 mg oral | |
| hydrocodone bitartrate er tablet 30 mg oral | |
| hydrocodone bitartrate er tablet 40 mg oral | |
| hydrocodone bitartrate er tablet 60 mg oral | |
| hydrocodone bitartrate er tablet 80 mg oral |
| aliskiren fumarate tablet 150 mg oral | |
| aliskiren fumarate tablet 300 mg oral |
| SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT INHALATION |
| UBRELVY TABLET 50 MG ORAL | |
| UBRELVY TABLET 100 MG ORAL |
Provider Actions and Prior Authorization
General Step Therapy Rule
Medications with 'ST' on the formulary require specified prior medication trials or concurrent therapy before a claim will process online. Step therapy is applied to ensure use of an effective, lower-cost alternative (or required concomitant therapy) prior to coverage of the requested product.
- Medications requiring a prior step or concurrent agent are indicated by 'ST' in the formulary Notes column.
- Independent Health prescription history is used to determine whether step or concurrent-therapy criteria are met for online processing.
Ubrelvy Step Rule and PA Trigger
A prescription for ubrogepant (Ubrelvy) will process online when 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 within 120 days, prior authorization is required.
- Affected product: UBRELVY (ubrogepant) tablets 50 mg, 100 mg.
- Step window: 120 days from date of request.
Uloric Step Rule and PA Trigger
A prescription for febuxostat (Uloric) will process online when the patient's Independent Health prescription history documents an allopurinol fill within the previous 90 days. If the pharmacy profile does not show a qualifying allopurinol fill within 90 days, prior authorization is required.
- Affected products: ULORIC (febuxostat) 40 mg and 80 mg tablets.
- Step window: 90 days from date of request.
Inhaled Corticosteroid / Spiriva Step Rule
For medications that require concurrent inhaled corticosteroid or Spiriva therapy, the prescription will process online only when the patient's Independent Health prescription history documents concurrent use of an inhaled corticosteroid or tiotropium (Spiriva). Prior authorization is required when the pharmacy profile does not demonstrate the required concurrent therapy.
- Concurrent therapy documented via Independent Health prescription history is acceptable for online processing.
- If concurrent inhaled corticosteroid or Spiriva use is absent from the pharmacy profile, submit a prior authorization request with supporting clinical documentation.
Required Documentation from Pharmacy Profile
When the pharmacy profile does not meet the applicable step or concurrency criteria, prior authorization is required. Independent Health relies on the member's prescription history in our pharmacy system to determine whether step therapy requirements are satisfied for online processing.
- Pharmacy history used for determination includes fills documented in Independent Health's prescription database.
- If the required prior fill or concurrent medication is not present, providers must submit a prior authorization request with clinical justification and supporting records.
Prior Authorization Required When History Criterion Not Met
Prior authorization required when the patient's pharmacy profile does not document the required prior or concurrent therapy described in the formulary step rules (for example: no qualifying generic triptan fill for Ubrelvy within 120 days; no allopurinol fill for Uloric within 90 days; no concurrent inhaled corticosteroid or Spiriva documented). Providers may be contacted by Member Services for additional information.
- If PA is required, include clinical rationale and relevant medication history in the PA submission.
- Contact Member Services: (716) 250-7183 or 1-833-891-9372, Monday–Friday 8 a.m.–8 p.m.; TTY 711.
Initial Therapy Criteria
GLP-1 initial therapy
GLP-1 initial authorization logic
Ubrelvy initial therapy requirement
Initial pharmacy processing rule
Uloric initial therapy requirement
Initial pharmacy processing rule
Unnamed medication initial therapy requirement
Initial pharmacy processing rule
Medication name not specified in source.
Step Therapy Rules
| Step | Requirement | If not met |
|---|---|---|
| 1 | ||
| Requires documented prior medication fills or concurrent therapy per product-specific lookback windows in the patient's Independent Health pharmacy profile | ||
| Prior authorization is required |
| Step | Requirement | If not met |
|---|---|---|
| 1 | ||
| Pharmacy history documents a generic triptan product filled within the previous 120 days | ||
| Prior authorization required |
| Step | Requirement | If not met |
|---|---|---|
| 1 | ||
| Pharmacy history documents an allopurinol fill within the previous 90 days | ||
| Prior authorization required |
| Step | Requirement | If not met |
|---|---|---|
| 1 | ||
| Pharmacy history documents concurrent use of an inhaled corticosteroid or Spiriva | ||
| Prior authorization required |
Definitions and Background
Step therapy is a utilization management protocol that requires trial of specified preferred or lower-cost medications (often generics or other designated agents) before coverage is provided for an alternative therapy. Medications requiring step therapy are indicated with an 'ST' in the formulary notes. The purpose of step therapy is to promote clinically appropriate, cost-effective treatment pathways and, where applicable, to document prior or concurrent use of specified medications in the member's pharmacy history before a new prescription will process online.
For questions about step therapy requirements or for assistance with Member Services, contact Independent Health at (716) 250-7183 or 1-833-891-9372, Monday–Friday, 8 a.m. to 8 p.m. TTY users should call 711.
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