Prior Authorization Required

Prior Authorization (PA) remains required for drugs listed with a 'PA' in the change listings. Providers must submit a prior authorization request (or medical exception request) to Independent Health for coverage of any drug flagged 'PA'. Do not assume PA is removed when a tier changes — review the specific drug entry.

• Affected examples: Cibinqo (all strengths) retain PA with the tier changes (see Tier Changes entries).
• Posaconazole (suspension and 100 mg tablet) are noted with PA after tier adjustments — PA is required. (See posaconazole entries.)
• Nitisinone (multiple strengths) entries include PA on new tiers — PA is required for these products.

PA Remains Required Where Listed

Prior authorization continues to apply where listed even when products change tiers or status. Several products moving tiers still require PA both before and after the change; providers must follow existing PA rules and submit required documentation.

• Many specialty and hepatitis C products (e.g., Epclusa, Sovaldi, Epclusa packs) show PA in both prior and new tier rows — submit PA per current criteria.
• Stelara and multiple Revlimid strengths were previously PA and are now designated NF; PA remains relevant for clinical exception requests.
• Cibinqo entries explicitly list PA on both Tier 2 and Tier 3 effective dates — ensure PA is included with any authorization request.

Prior Authorization Additions

New prior authorization assignments have been added for selected products. When a drug is newly assigned PA in the change listing, providers must obtain PA before the plan will cover the medication.

• Posaconazole suspension and posaconazole 100 mg tablets are newly listed with PA effective 1/1/2026 (moved from 9/1/2025 entries).
• Nitisinone formulations (2 mg, 5 mg, 10 mg, 20 mg) show PA assignments across impacted formularies and effective dates — follow PA rules.
• Examples of other products newly shown as NF may still require PA for medical exceptions (e.g., Stelara entries).

Non‑Formulary Triggers Denial

Non-Formulary (NF) designations will result in coverage denial under the formulary benefit unless a medical exception is approved. Providers should expect denied claims when the drug is designated NF as of the listed effective date unless an approved exception is on file.

• Drugs listed as 'NF' (for example: Stelara effective 7/1/2025; multiple Revlimid strengths effective 10/1/2025; many entries effective 1/1/2026) will no longer be covered under the formulary.
• If an alternative formulary drug is available, those alternatives are listed in the change entries — consider switching to the listed alternative prior to submitting an exception.
• For NF drugs, submit a medical exception request with supporting clinical documentation if coverage is medically necessary.

Step Therapy (ST) Applies

Step Therapy (ST) applies where indicated. When a drug is listed with 'ST' in the change details, providers must ensure step therapy requirements are met or submit documentation supporting an exception.

• Victoza is listed as ST prior to becoming NF — follow existing step therapy rules until the NF date (Victoza NF 10/1/2025).
• Sancuso transdermal patch is listed with ST prior to NF — ensure step requirements are met prior to 7/1/2026.
• If a product retains ST on the new tier, continue to follow step edits when prescribing and authorizing.

Preferred Alternatives / Substitution Mapping

Preferred alternatives and substitution options are listed for many changed drugs. When a non‑preferred or NF product has an indicated alternative, consider the listed alternatives prior to seeking an exception.

• Hepatitis C: Epclusa and Sovaldi entries list preferred alternatives such as Mavyret, sofosbuvir‑velpatasvir, or ledipasvir‑sofosbuvir — use preferred agents when clinically appropriate.
• Stelara and multiple biologics: Alternatives listed include adalimumab, Yesintek, Selarsdi, Rinvoq, Xeljanz, Skyrizi, Taltz, Otezla, Entyvio, Actemra, Kevzara, Zeposia, Orencia.
• For stimulant/ADHD products (e.g., lisdexamfetamine moving to Tier 3), alternatives include amphetamine‑dextroamphetamine, dextroamphetamine, dexmethylphenidate, and methylphenidate formulations.

Record Effective Date for Requests and Counseling

Document the effective dates and PA/ST status when submitting prior authorization or counseling members. Recordkeeping of the change effective date is essential because coverage, PA, ST, and NF statuses are date‑dependent.

• Examples: Cibinqo tier and PA changes are effective 1/1/2026 — ensure authorization requests reflect the correct effective date.
• Multiple posaconazole and nitisinone entries show effective date 1/1/2026 — verify member coverage and PA requirements on or after that date.
• Keep copies of submitted PA and clinical documentation tied to the date of service and the effective date of the formulary change.

Provider Operational Reminders

Action items and general provider obligations: verify formulary status and PA/ST requirements at the point of prescribing; consider listed alternatives before seeking exceptions; submit full clinical documentation with PA/exception requests; expect denials for NF drugs absent an approved exception.

• Check the member's specific drug formulary and benefit prior to dispensing or authorizing.
• For PA submissions include indication, prior therapies, clinical rationale, and relevant lab or diagnostic results.
• When an alternative is listed, first discuss substitution with the member and prescribing clinician to avoid unnecessary exceptions or denials.

Verify Abrilada (adalimumab biosimilar) SKU tier and PA status

Abrilada (adalimumab biosimilar) presentations are listed with Drug Formulary group assignments and some pack sizes retain Tier 2 with 'PA' while other Abrilada SKUs are shown as 'NF'; verify the specific Abrilada SKU's tier and PA status before prescribing or billing.

• Abrilada 40mg/0.8ml autoinjector and 20mg/0.4ml syringe entries show Tier 2 with PA for certain pack sizes and NF for others effective 1/1/2026.
• Confirm whether a given Abrilada SKU is NF or requires PA prior to dispensing or submitting a claim.