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STEP THERAPY CRITERIA - OpenPayer

v1.0.10

OpenPayerPolicy UpdatesPharmacy & Specialty DrugsSTEP THERAPY CRITERIA

CurrentIndependent HealthPolicy N/A

STEP THERAPY CRITERIA

Step therapy protocols for Pharmacy Benefit Dimensions Prescription Drug Plan (PDP) Part D 3 Tier Formulary current as of March 1, 2026, listing prior-therapy requirements for specific products. Governs which prior drugs must be tried before coverage is allowed for listed products.

Policy Summary

PayerIndependent Health

PolicySTEP THERAPY CRITERIA

Policy CodePolicy N/A

Change TypeClarified step therapy requirements

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionPrescribers must document prior prescription history showing the required step drug(s) (e.g., ARB for aliskiren, allopurinol for febuxostat, clobazam suspension for Sympazan, Lupron Depot for Trelstar, clozapine ODT for Versacloz, calcitriol for doxercalciferol) to obtain coverage for the listed products.

POLICY UPDATE CHANGES

Step therapy list current as of March 1, 2026 with specified prior-therapy requirements for listed products.

18Products with step requirements listed

1Formulary referenced (PDP Part D 3 Tier)

Summary of changes and scope

Independent Health (Pharmacy Benefit Dimensions PDP) uses step therapy to require trial of specified agents before covering alternative products. This bulletin lists per-product prior-therapy requirements for the 2026 Pharmacy Benefit Dimensions Prescription Drug Plan (PDP) Part D 3 Tier Formulary, and the step therapy list is current as of March 1, 2026.

Key facts

Effective dateMarch 1, 2026

PayerIndependent Health (Pharmacy Benefit Dimensions PDP)

Formulary referenced2026 Pharmacy Benefit Dimensions PDP Part D 3 Tier Formulary

Products with step requirements listed18

Step therapy criteria (per-product)

Aliskiren products - Prior ARB requirement

Covered when ALL of the following are met:

ALL of the following

Prior prescription history of an ARB

ALL of the following

Prior prescription history of an ARB

Aripiprazole ODT/film - sequence requirement

Covered when ALL of the following are met:

Aripiprazole orally-disintegrating tablet (ODT) requires prior use of aripiprazole oral solution

Aripiprazole oral films require prior use of aripiprazole ODT

Eucrisa (crisaborole) ointment - prior topical therapy

Covered when ALL of the following are met:

ALL of the following

Prior prescription history positive for the use of either a topical corticosteroid or topical calcineurin inhibitor

Febuxostat - allopurinol prior requirement

Covered when ALL of the following are met:

ALL of the following

Requires prior use of allopurinol

ALL of the following

Requires prior use of allopurinol

Sympazan (clobazam) films - suspension first

Covered when ALL of the following are met:

ALL of the following

Requires prior use of clobazam oral suspension

Trelstar MixJect (triptorelin) - Lupron step

Covered when ALL of the following are met:

ALL of the following

Requires prior use of Lupron Depot

Versacloz suspension - clozapine ODT prior

Covered when ALL of the following are met:

ALL of the following

Requires prior use of clozapine orally-disintegrating tablet (ODT)

Doxercalciferol capsules - prior calcitriol

Covered when ALL of the following are met:

ALL of the following

Prior prescription history includes past use of calcitriol

Affected products (formulary names)

Listed products (by exact product names in formulary)mixed

aliskiren fumarate tablet 150 mg oral	Product affected; requires prior ARB
aliskiren fumarate tablet 300 mg oral	Product affected; requires prior ARB
aripiprazole tablet dispersible 10 mg oral	ODT product; sequence requirement
aripiprazole tablet dispersible 15 mg oral	ODT product; sequence requirement
OPIPZA FILM 2 MG ORAL	oral film; sequence requirement
OPIPZA FILM 5 MG ORAL	oral film; sequence requirement
OPIPZA FILM 10 MG ORAL	oral film; sequence requirement
EUCRISA OINTMENT 2 % EXTERNAL	Topical; requires prior topical corticosteroid or calcineurin inhibitor
febuxostat tablet 40 mg oral	Requires prior allopurinol
febuxostat tablet 80 mg oral	Requires prior allopurinol

1–10 of 20

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What prescribers must do

Step Therapy

Step therapy prior use requirement

Prescribers must document prior prescription history showing the required step drug(s) before coverage will be allowed for the listed products. Examples include prior ARB for aliskiren products, prior allopurinol for febuxostat, prior clobazam oral suspension for Sympazan films, prior Lupron Depot for Trelstar MixJect, prior clozapine ODT for Versacloz suspension, and prior calcitriol for doxercalciferol capsules.

aliskiren fumarate tablet 150 mg oral -> ARB
aliskiren fumarate tablet 300 mg oral -> ARB
febuxostat tablet 40 mg oral / 80 mg -> allopurinol
SYMPAZAN FILM (5 mg, 10 mg, 20 mg) -> clobazam oral suspension
TRELSTAR MIXJECT SUSPENSION (3.75 mg, 11.25 mg, 22.5 mg IM) -> Lupron Depot
VERSACLOZ SUSPENSION 50 mg/mL -> clozapine ODT
doxercalciferol capsules (0.5, 1, 2.5 mcg) -> calcitriol
EUCRISA OINTMENT 2% -> topical corticosteroid or topical calcineurin inhibitor
Aripiprazole sequence: aripiprazole oral solution -> aripiprazole ODT -> aripiprazole oral film

Prescribers must document prior prescription history demonstrating the required prior agent(s) as specified for each product to obtain coverage; the step therapy list and documentation expectations are effective and current as of 2026-03-01.

Definitions

Step Therapy: A protocol requiring trial of certain drugs to treat a condition before coverage of another drug for that condition is allowed.

Document changes

2026-03-01clarifiedLatest

Step therapy list current as of March 1, 2026 with specified prior-therapy requirements for listed products.

2026-03-01clarified

Aliskiren fumarate tablets (150 mg and 300 mg) require prior prescription history of an ARB.

2026-03-01clarified

Aripiprazole ODT requires prior use of aripiprazole oral solution; aripiprazole oral films require prior use of aripiprazole ODT.

2026-03-01clarified

Eucrisa ointment (2%) requires prior use of a topical corticosteroid or a topical calcineurin inhibitor.

2026-03-01clarified

Febuxostat tablets (40 mg and 80 mg) require prior use of allopurinol.

2026-03-01clarified

Sympazan oral films (5 mg, 10 mg, 20 mg) require prior use of clobazam oral suspension.

2026-03-01clarified

Trelstar MixJect suspensions (3.75 mg, 11.25 mg, 22.5 mg IM) require prior use of Lupron Depot.

2026-03-01clarified

Versacloz suspension (50 mg/mL) requires prior use of clozapine orally-disintegrating tablet (ODT).

2026-03-01clarified

Doxercalciferol capsules (0.5 mcg, 1 mcg, 2.5 mcg) require prior prescription history showing past use of calcitriol.

Policy Summary

PayerIndependent Health

PolicySTEP THERAPY CRITERIA

Policy CodePolicy N/A

Change TypeClarified step therapy requirements

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionPrescribers must document prior prescription history showing the required step drug(s) (e.g., ARB for aliskiren, allopurinol for febuxostat, clobazam suspension for Sympazan, Lupron Depot for Trelstar, clozapine ODT for Versacloz, calcitriol for doxercalciferol) to obtain coverage for the listed products.

On This Page

Summary of changes and scope Step therapy criteria (per-product)Affected products (formulary names)What prescribers must do Definitions Document changes