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Prior Authorization Criteria for Medicare Part D Formulary Drugs

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Lists prior authorization (PA) requirements for drugs on Independent Health's 2026 Medicare Advantage Part D formulary; applies to providers and pharmacists seeking coverage for listed medications for Medicare members.

Policy Summary

PayerIndependent Health

PolicyPrior Authorization Criteria for Medicare Part D Formulary Drugs

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateJan 14, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with required diagnosis, relevant labs/genetic or tumor testing, documentation of prior therapies or failures, prescriber specialty and pregnancy status as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+products shown in this excerpt

1 yeartypical coverage duration

manyrequires prior therapies

frequentdiagnostic testing required

Coverage Criteria and Drug-Specific Authorization Rules

Biologic/immunomodulatory drugs — initial authorization

Covered when ALL of the following are met for biologic/immunomodulatory drugs (except Otezla and Velsipity):

Biologic initial authorization: Patient has a diagnosis for the requested FDA‑approved use; patient has tried and failed, or has intolerance/contraindication to, at least two preferred agents where possible (examples: an adalimumab biosimilar, Cosentyx, Enbrel, Rinvoq, Skyrizi, an ustekinumab biosimilar, Xeljanz/Xeljanz XR); baseline latent tuberculosis screening (PPD or IGRA) performed with documented result (if positive, latent TB must be treated prior to initiation); prescriber specialty as required by product entry; pregnancy status submitted for females of childbearing potential.

Applies to all drugs managed by this biologic/immunomodulatory group except Otezla and Velsipity; annual TB screening or chest X‑ray may be required for ongoing therapy in patients at risk.

Pulmonary hypertension (PAH) — initial authorization

Covered when ALL of the following are met for pulmonary hypertension agents (example: ADEMPAS):

PAH initial authorization: Diagnosis confirmed by right heart catheterization with mean pulmonary arterial pressure >20 mm Hg at rest and pulmonary arterial wedge pressure ≤15 mm Hg; submission of WHO Group classification (attest WHO Group 1 if applicable); submission of pulmonary vascular resistance (PVR) >2 Wood units for WHO Group 1 (or >3 Wood units for CTEPH where specified); submission of creatinine clearance (or serum creatinine, weight, height to calculate); pregnancy status submitted for females of childbearing potential; documentation of prior trial and inadequate response or intolerance to both (1) a phosphodiesterase‑5 inhibitor (sildenafil or tadalafil) and (2) an endothelin receptor antagonist (ambrisentan or bosentan) for WHO Group 1 when required.mPAP >20 mm Hg; PAWP ≤15 mm Hg; PVR >2 WU

Prescriber restricted to cardiology or pulmonology; age ≥18; coverage duration 1 year.

ARIKAYCE — initial authorization

Covered when ALL of the following are met for ARIKAYCE (MAC lung disease):

ARIKAYCE initial authorization: Diagnosis of refractory Mycobacterium avium complex (MAC) lung disease; documentation that the patient has tried and failed a guideline‑based multi‑drug MAC regimen (e.g., ethambutol, a macrolide, and a rifamycin) for at least 6 months; submission of a positive sputum culture obtained after treatment with the multi‑drug regimen; prescriber restricted to infectious disease or pulmonology; age ≥18.6 months trial of multi‑drug MAC regimen

Coverage duration 1 year; ARIKAYCE is not covered for non‑refractory MAC disease.

Caplacizumab — initial authorization

Covered when ALL of the following are met

caplacizumab_initial: Diagnosis of the covered use (aTTP) and documentation the drug will be administered with plasma exchange and concurrent immunosuppressive therapy; if not the patient's first use, submission of prior aTTP recurrences while on caplacizumab is required and coverage will not be authorized if patient has had more than 2 recurrences while on therapy.age >=18

Prescriber restricted to cardiology, hematology, or immunology; coverage duration 3 months.

Mavacamten (CAMZYOS) — initial authorization

Covered when ALL of the following are met

mavacamten_initial: Attestation patient has exertional symptoms consistent with NYHA class II or III; confirmation of left ventricular outflow tract (LVOT) gradient ≥50 mm Hg at rest, with Valsalva, or after exercise; LV wall thickness ≥15 mm (or ≥13 mm if familial); submission of current left ventricular ejection fraction (LVEF); documentation patient has tried and failed or is intolerant to both a beta‑blocker and a non‑dihydropyridine calcium channel blocker prior to initiation.LVOT gradient >=50 mm Hg; LV wall thickness >=15 mm (or >=13 mm if familial); age >=18

Prescriber restricted to cardiology; coverage duration 1 year.

CFTR modulators — initial authorization

Covered when ALL of the following are met

cftr_modulators: Diagnosis of cystic fibrosis for an FDA‑approved indication and submission of CFTR mutation testing confirming the presence of the specific mutation(s) predicted to be responsive to the requested CFTR modulator per the product prescribing information (mutation requirements vary by product).

Prescriber restricted to pulmonology; coverage duration 1 year; mutation‑specific requirements apply per product (e.g., ivacaftor, lumacaftor/ivacaftor, tezacaftor/ivacaftor, elexacaftor/tezacaftor/ivacaftor).

Emgality — migraine

Covered when ALL of the following are met

emgality_migraine_prevention: Diagnosis of migraine for the requested indication; for prevention submit baseline number of headache days per month; for prevention the patient must have tried and had inadequate response or intolerance to Aimovig prior to Emgality; for acute migraine treatment the patient must have tried and failed at least one triptan or have a documented contraindication to triptan use.age >=18

Initial prevention authorization 3 months then 1 year; acute migraine initial authorization 1 year; first reauthorization for prevention requires on‑treatment headache days demonstrating improvement.

Dupilumab — indication-specific criteria

Covered when ALL of the following are met (indication-specific criteria apply)

dupilumab_general

AD: Atopic dermatitis: objective documentation of ≥10% body surface area involvement AND trial and inadequate response or contraindication to at least a moderate‑strength topical corticosteroid for ≥4 weeks (or documentation why topical steroid is not advisable).4 weeks
Asthma: pre‑bronchodilator FEV1 <80% predicted (adults) or <90% (children) AND either blood eosinophils ≥150 cells/mcL within 6 weeks OR documentation that patient requires daily oral corticosteroid for control; patient must be on GINA‑recommended regimen (maximally‑tolerated ICS + LABA + LAMA) prior to biologic and provider must attest therapy will continue after starting dupilumab.FEV1 and eosinophil thresholds per node
Reauthorization requires continued background therapy and evidence of benefit.
COPD: post‑bronchodilator FEV1/FVC <0.7 and post‑bronchodilator FEV1 30–80% predicted AND blood eosinophils ≥300 cells/mcL within 6 weeks AND symptomatic disease defined by mMRC ≥2 OR CAT ≥10; must be on stable ICS+LABA+LAMA for ≥90 days pre‑initiation and provider must attest therapy will continue.>=90 days; mMRC >=2 OR CAT >=10
Reauthorization requires maintenance of benefit and continued triple therapy.
CRSwNP: Chronic rhinosinusitis with nasal polyps: evidence of nasal polyps and symptomatic nasal congestion AND trial of intranasal corticosteroid for ≥2 months (or contraindication) with provider attestation intranasal steroid will continue after starting dupilumab.2 months
Reauthorization requires documentation of clinical benefit or maintenance.
EoE: Eosinophilic esophagitis: upper endoscopy with biopsy showing ≥15 eos/hpf or 60 eos/mm2 AND documentation of signs/symptoms (e.g., dysphagia) AND failure of an 8‑week PPI trial.>=15 eos/hpf; failed 8‑week PPI
Reauthorization requires documentation of clinical benefit.
PN: Prurigo nodularis: pruritus ≥6 weeks and presence of multiple pruriginous firm nodular lesions with documentation of prior therapies tried; reauthorization requires documentation of clinical benefit.6 weeks

DOPTELET — indications and requirements

Covered when ALL of the following are met

doptelet_indications: Indication‑specific requirements: (A) For thrombocytopenia in chronic liver disease scheduled for a procedure: platelet count <50 x10^9/L and documentation of the scheduled procedure (duration 5 days). OR (B) For immune thrombocytopenia (ITP): platelet count <30 x10^9/L (or <50 x10^9/L with symptomatic bleeding), documentation patient has undergone splenectomy OR tried and failed at least two ITP therapies from different classes (systemic corticosteroids, IVIG, danazol, fostamatinib, or cytotoxics/immunosuppressants); initial ITP authorization initially 2 months then 1 year; first reauthorization for ITP requires platelet improvement ≥50 x10^9/L after ≥4 weeks on maximum tolerated dose.<50 x10^9/L (procedure) OR <30 x10^9/L (ITP) or <50 x10^9/L with symptomatic bleeding

Prescriber specialties limited to gastroenterology, hematology, hepatology, surgery; coverage duration varies by indication.

Initial authorization — Atopic dermatitis (AD)

Covered when ALL of the following are met for indication-specific initial authorization (examples provided):

Atopic dermatitis initial auth: Patient has documented trial and inadequate response to at least a moderate‑strength topical corticosteroid for at least 4 weeks, or has a contraindication to topical corticosteroids, or documentation why topical steroid is not advisable.4 weeks

Provider must document prior topical therapy or contraindication.

Initial authorization — Asthma

Covered when ALL of the following are met for asthma initial authorization:

Asthma initial auth: Patient is on a drug regimen as recommended by GINA (at minimum maximally‑tolerated inhaled corticosteroid [ICS] + long‑acting beta‑agonist [LABA] + long‑acting muscarinic antagonist [LAMA]) prior to biologic initiation and provider attests this therapy will be continued after starting the biologic; submit pre‑bronchodilator FEV1 and blood eosinophil counts per product thresholds where applicable.FEV1 and eosinophil thresholds per product

Provider attestation required; reauthorization requires documentation of clinical benefit or maintenance.

Initial authorization — COPD

Covered when ALL of the following are met for COPD initial authorization:

COPD initial auth: Patient has been on stable doses of standard‑of‑care COPD medications including an ICS, LABA, and LAMA for at least 90 days prior to starting biologic therapy unless contraindicated and provider attests therapy will be continued; patient meets symptomatic threshold defined by either mMRC ≥2 OR CAT ≥10.>=90 days; mMRC >=2 OR CAT >=10

Both medication stability and symptom threshold required; prescriber specialty as listed per product.

Initial authorization — CRSwNP

Covered when ALL of the following are met for chronic rhinosinusitis with nasal polyps (CRSwNP) initial authorization:

CRSwNP initial auth: Documentation of nasal polyps and symptomatic nasal congestion AND trial of intranasal corticosteroid for at least 2 months (or contraindication) with provider attestation intranasal corticosteroid will be continued after starting biologic therapy.2 months

Prescriber specialty restrictions apply; reauthorization requires documentation of clinical benefit or maintenance.

Reauthorization criteria

For reauthorization of chronic conditions (examples):

Asthma/COPD reauthorization: Confirmation patient remains on indicated background therapy (e.g., triple ICS‑LABA‑LAMA for asthma/COPD unless contraindicated) AND documentation of clinical benefit or maintenance of previously achieved benefit (examples: reduced exacerbation rate, decreased systemic steroid use, improved FEV1 or symptom scores).

Required at each reauthorization; prescriber must submit objective measures per product guidance.

CRSwNP reauthorization: Confirmation patient continues intranasal corticosteroid use unless contraindicated AND documentation of clinical benefit (e.g., reduction in nasal congestion, nasal polyp score, or systemic corticosteroid dose) or maintenance of prior benefit.

Required at each reauthorization.

AD/PN reauthorization: Documentation of clinical benefit such as reduction in itch severity or proportion of body affected, or maintenance of previously achieved benefit.

Required at each reauthorization.

EoE reauthorization: Documentation of clinical benefit such as histologic remission or reduction in dysphagia, or maintenance of previously achieved benefit.

Required at each reauthorization.

Eltrombopag (examples)

Covered when ALL of the following are met for eltrombopag indications (examples):

ITP initial auth: Diagnosis of immune thrombocytopenia (ITP) with platelet count <30 x10^9/L (or <50 x10^9/L with increased bleeding risk) AND documentation patient has undergone splenectomy or has tried and failed two different ITP therapies (systemic corticosteroids, IVIG, danazol, fostamatinib, or cytotoxic/immunosuppressive agents such as rituximab).<30 x10^9/L or <50 x10^9/L with increased bleeding risk

Initial authorization 12 weeks then 1 year; prescriber specialties restricted to gastroenterology/hematology/hepatology/infectious disease as applicable.

Chronic HCV thrombocytopenia: Platelet count <75 x10^9/L and attestation patient will receive interferon therapy to treat HCV.<75 x10^9/L

Coverage duration 1 year.

Aplastic anemia: Platelet count <30 x10^9/L and submission of planned concomitant immunosuppressive therapy or documentation of refractory disease after prior therapies.<30 x10^9/L

Coverage duration 6 months as specified.

Eosinophilic esophagitis

Covered when ALL of the following are met for eosinophilic esophagitis:

EoE initial auth: Diagnosis confirmed by upper endoscopy with biopsy demonstrating ≥15 eosinophils per high‑power field (or 60 eos/mm2) AND documentation of compatible signs/symptoms (e.g., dysphagia) AND failure of an adequate 8‑week proton pump inhibitor trial.>=15 eos/hpf; failed 8‑week PPI

Age ≥11 years; coverage duration 12 weeks with a maximum of one 12‑week course per 365 days.

ALK-positive oncology agents

Covered when ALL of the following are met for ALK-positive oncology agent initial authorization:

ALK inhibitor initial auth: Tumor testing confirming ALK‑positive status submitted; patient has not previously received an ALK inhibitor for the same indication (unless product allows otherwise); pregnancy status submitted for females of childbearing potential.

Prescriber restricted to oncology; age ≥18; exclusion criteria (e.g., severe hepatic impairment, interacting drugs) absent.

FILSPARI — primary IgA nephropathy

Covered when ALL of the following are met for FILSPARI (IgA nephropathy):

FILSPARI initial auth: Biopsy‑confirmed primary IgA nephropathy; 24‑hour urine protein ≥0.5 g/day OR urine protein‑to‑creatinine ratio (UPCR) ≥0.8 g/g; submission of eGFR and liver function testing or Child‑Pugh score; pregnancy status for females of childbearing potential; patient is currently using (or has documented intolerance/contraindication to) a maximally‑tolerated ACE inhibitor or ARB.>=0.5 g/day or UPCR >=0.8 g/g

Prescriber restricted to immunology or nephrology; annual reauthorization requires documentation of response (stabilization or improvement of UPCR); coverage duration 1 year.

Oncology prior therapy requirements

Covered when ALL of the following are met for specified oncology agents:

FOTIVDA initial auth: Diagnosis of covered oncologic use; submission of baseline blood pressure and liver function testing/Child‑Pugh score; documentation of prior systemic therapies showing failure of at least two prior regimens including at least one prior VEGFR inhibitor where specified; pregnancy status for females of childbearing potential and cardiovascular safety attestations as required.failure of >=2 systemic therapies where specified

Prescriber restricted to oncology; age ≥18; coverage duration 1 year.

FRUZAQLA initial auth: Diagnosis and baseline blood pressure; documentation of prior chemotherapy regimens (fluoropyrimidine, oxaliplatin, irinotecan), prior anti‑VEGF therapy, and anti‑EGFR therapy if RAS wild‑type and appropriate; pregnancy status and cardiovascular history documentation.prior specific regimens required

Prescriber restricted to oncology; age ≥18; coverage duration 1 year.

Product-specific authorization criteria (summary)

Covered when ALL of the following product-specific conditions are met (per product):

Common requirements: Diagnosis of covered use for the specific product; submission of required tests or genetic/tumor testing where specified (e.g., ROS1, ALK, BRCA, RET, PIK3CA); submission of pregnancy status for females of childbearing potential where required; prescriber specialty restrictions as listed for each product; patient meets age restriction for the product; absence of listed exclusions (drug interactions, severe hepatic impairment, prolonged QT, etc.); coverage duration as specified by product (commonly 1 year unless otherwise noted).

Product‑specific prior therapy, laboratory, or mutation requirements must also be met as detailed in each product entry.

LENVIMA coverage criteria

Covered when PA criteria for the specific drug are satisfied with required documentation and absence of exclusions

LENVIMA initial/maintenance: Patient ≥18 years; diagnosis of covered use; pregnancy status submitted for females of childbearing potential; for maintenance post auto‑HSCT ANC ≥1,000/mcL and platelets ≥75,000/mcL; indication‑specific prior therapy requirements documented (e.g., mantle cell lymphoma: ≥2 prior therapies one including bortezomib or documented contraindication); prescriber restricted to hematology/oncology; coverage duration 1 year.ANC >=1000/mcL and platelets >=75,000/mcL for post‑auto‑HSCT maintenance

Adhere to product exclusions such as pregnancy; prior therapy prerequisites apply per indication.

LYNPARZA coverage criteria

LYNPARZA coverage requires specific genetic testing and prior therapy attestations depending on indication

LYNPARZA initial: Patient ≥18; diagnosis of covered use; pregnancy status submitted for females of childbearing potential; submission of BRCA mutation or homologous recombination deficiency testing as required per indication; indication‑specific prior therapy requirements documented (examples: ovarian — response to platinum‑based chemotherapy; breast — prior chemotherapy and endocrine therapy for HR+ disease; pancreatic — no progression after ≥16 weeks platinum chemotherapy; prostate — progressed after abiraterone or enzalutamide), prescriber restricted to oncology or urology; coverage duration 1 year.

Genetic/tumor testing must be submitted per indication.

NUCALA coverage criteria (asthma, CRSwNP, EGPA, HES)

NUCALA covered when clinical and laboratory criteria are met for the specific eosinophilic conditions

NUCALA asthma: Diagnosis of severe eosinophilic asthma; patient on maximally‑tolerated ICS + LABA + LAMA per GINA prior to biologic with provider attestation therapy will be continued; pre‑bronchodilator FEV1 <80% predicted in adults (<90% in children) AND blood eosinophils ≥150 cells/mcL within 6 weeks OR ≥300 cells/mcL within 12 months; submission of current and prior therapies; prescriber specialty restrictions apply; coverage duration 1 year; reauthorization requires confirmation of continued triple inhaler use and documentation of clinical benefit or maintenance.eosinophil thresholds per node

NUCALA CRSwNP: Documented nasal polyps and symptomatic nasal congestion; trial of intranasal corticosteroid for ≥2 months (or contraindication) with provider attestation intranasal steroid will continue; prescriber specialties as above; coverage duration 1 year; reauthorization requires documentation of benefit.2 months

NUCALA EGPA/HES: EGPA: eos% ≥10% OR absolute eos ≥1000 cells/mm3 in prior 6 weeks AND disease relapsed/refractory to oral corticosteroids and/or immunosuppressives for ≥6 months. HES: uncontrolled disease defined as ≥2 flares requiring systemic therapy in prior 12 months AND blood eos ≥1000 cells/mcL in prior 6 weeks; attest HES lacks identifiable non‑hematologic secondary cause; reauthorization requires documentation of clinical benefit or maintenance.eosinophil thresholds per node

LORBRENA coverage criteria

Covered when PA criteria for the specific drug are satisfied with required documentation and absence of exclusions

LORBRENA: Patient ≥18; ALK‑positive tumor confirmed by testing; submission of baseline blood pressure and pregnancy status for females of childbearing potential; coadministration with strong CYP3A inducers is excluded; prescriber restricted to oncology; coverage duration 1 year.

Adhere to product‑specific exclusions and prior therapy requirements where applicable.

Example: Nuedexta initial and reauthorization criteria

Covered when ALL of the following are met for drugs with QT risk (example: NUEDEXTA):

Nuedexta initial criteria: Diagnosis of covered use; submission of baseline serum potassium and magnesium levels; ECG evaluation of baseline QT interval when increased QT risk is present; prescriber restricted to neurology or psychiatry; age ≥18; absence of listed exclusions (e.g., agitation/Alzheimer's without PBA, prolonged QT, congenital long QT syndrome, heart failure, history suggestive of torsades de pointes, AV block without pacemaker, uncorrected hypokalemia/hypomagnesemia, recent non‑selective MAOI use).

Coverage duration 1 year; annual reauthorization requires updated potassium/magnesium and documentation of symptomatic or maintained improvement.

Targeted oncology therapy criteria

Covered for targeted oncology agents when ALL of the following apply:

Genetic/tumor testing required: Diagnosis of covered use; submission of tumor or genetic testing confirming the required mutation, fusion, or biomarker for the requested targeted agent (examples: PIK3CA for PIQRAY, FGFR alterations for Pemazyre); attestation of prior therapies tried/failed where required by indication; prescriber restricted to oncology; age ≥18; absence of listed exclusions (e.g., coadministration with contraindicated strong CYP3A4 inducers).

Coverage duration generally 1 year; product‑specific testing and prior therapy requirements must be provided.

Prolastin-C criteria

Covered for Prolastin-C when ALL of the following are met:

Alpha-1 antitrypsin deficiency criteria: Pre‑treatment alpha‑1 antitrypsin (AAT) level <11 mmol/L (80 mg/dL) submitted; confirmation of clinically evident emphysema attributable to congenital alpha‑1 PI deficiency by pulmonary function testing or imaging (e.g., spirometry, DLCO, radiography); patient not IgA‑deficient with known anti‑IgA antibodies; prescriber restricted to pulmonology; age ≥18.AAT <11 mmol/L (80 mg/dL)

Reauthorization requires confirmation of symptomatic or clinical improvement or maintenance; Part B vs Part D determination may apply depending on administration setting; coverage duration 1 year.

Pulmonary arterial hypertension agents - initial authorization

Covered when ALL of the following are met (example: pulmonary arterial hypertension agents)

PAH agents initial auth: Diagnosis confirmed by right heart catheterization with mean pulmonary arterial pressure >20 mm Hg at rest, pulmonary arterial wedge pressure ≤15 mm Hg, and pulmonary vascular resistance >2 Woods units; attestation patient is WHO Group 1 when applicable; submission of pregnancy status for females of childbearing potential for endothelin receptor antagonists (ambrisentan, bosentan, Opsumit); prescriber restricted to cardiology or pulmonology; age ≥18 for listed agents unless otherwise specified; for Opsumit initial authorization document trial and inadequate response or intolerance to ambrisentan or bosentan.mPAP >20 mm Hg; PAWP ≤15 mm Hg; PVR >2 WU

Coverage duration 1 year; includes product‑specific hepatic/renal exclusions as applicable.

Cushing's syndrome agents - initial and reauthorization

Covered when ALL of the following are met (example: agents for Cushing's syndrome)

Cushing's syndrome initial auth: Diagnosis of Cushing's syndrome with 24‑hour urine free cortisol (UFC) >1.5× ULN (≥50 mcg or 145 nmol) submitted; attestation pituitary surgery is not an option or was not curative; ECG including QTcF and liver function tests performed within 3 months of request; documentation patient tried and failed at least one other therapy (e.g., mifepristone, pasireotide); prescriber restricted to endocrinology.24‑hour UFC >1.5× ULN

Coverage duration 1 year; exclusion for baseline AST/ALT >3× ULN or prolonged QTcF >470 msec; reauthorization requires documentation of clinically relevant response or maintenance.

Oncology targeted therapies - diagnostic confirmation required

Covered when ALL of the following are met (oncology targeted therapies)

RET-targeted agents: Diagnosis of covered use with submission of testing confirming RET gene fusion or mutation; baseline blood pressure and pregnancy status submitted for females of childbearing potential; for RET fusion‑positive thyroid cancer attest patient is radioactive iodine‑refractory or ineligible; prescriber restricted to oncology; coverage duration 1 year.

Excludes uncontrolled hypertension and coadministration with moderate/strong CYP3A inducers where specified.

ROS1/NTRK-targeted agents: Diagnosis of covered use with submission of ROS1 or NTRK gene fusion testing as applicable; for NTRK attest fusion without known acquired resistance mutation and that tumor is metastatic or other systemic therapies are unsatisfactory; pregnancy status submitted for females of childbearing potential; prescriber restricted to oncology; coverage duration 1 year.

Excludes coadministration with moderate/strong CYP3A inducers or QT‑prolonging drugs as specified.

PCSK9 inhibitors - Repatha

Covered when ALL of the following are met (PCSK9 inhibitors example)

Repatha initial authorization criteria: Indication is FDA‑approved; age and prescriber restrictions met (e.g., age ≥10 for select indications; prescriber restricted to cardiology/endocrinology/specialists in cardiovascular risk management); for reducing MACE or heterozygous familial hypercholesterolemia the patient must have tried and failed to achieve LDL <70 mg/dL despite ≥8 weeks of high‑intensity statin therapy OR experienced statin‑induced rhabdomyolysis OR have documented intolerance to atorvastatin and rosuvastatin; for homozygous FH additional pathways include statin intolerance or inadequate LDL response despite high‑intensity statin therapy.LDL <70 mg/dL after statin trial where applicable

Coverage duration 1 year; prior therapy documentation required per indication.

Reauthorization and monitoring requirements

Reauthorization requires demonstration of ongoing benefit for several agents

Hepatology agent reauthorization: First reauthorization requires documentation confirming resolution, improvement, or stabilization of disease (e.g., improvement or stabilization of fibrosis stage by biopsy or noninvasive testing); annual reauthorization requires maintenance of clinical benefit.

Applies to agents treating fibrosis/NASH per product entry.

Somavert reauthorization: First reauthorization requires updated IGF‑1 demonstrating improvement from baseline and LFTs with transaminases <5× ULN and attestation patient has no signs/symptoms of liver injury; annual reauthorization requires documented improvement or maintenance of IGF‑1.LFT transaminases <5× ULN for first reauth

Prescriber restricted to endocrinology.

Drug-specific medical necessity requirements (aggregate)

Covered when all specified drug-specific requirements are met (diagnosis, required testing, prescriber restriction, and absence of listed exclusions).

General drug-specific requirements: Diagnosis of covered use; submission of required baseline labs or genetic/tumor testing when specified; prescriber specialty restrictions observed; age restriction met where specified; absence of listed exclusion criteria (drug interactions, comorbid conditions); coverage duration as specified by product.

Apply product‑level details found in each product’s section (chunks referenced).

Teriparatide criteria

Teriparatide (subcutaneous pen-injector) initial and reauthorization criteria

Initial authorization for teriparatide: Documentation patient meets 'high risk for fracture' criteria (hip or vertebral fracture history regardless of BMD; or specified T‑score/FRAX criteria) AND prior trial and failure or intolerance to at least one bisphosphonate (therapeutic failure defined as fracture or decrease in BMD while on bisphosphonate ≥3 months); baseline serum calcium submitted; age and other exclusions absent.prior bisphosphonate >=3 months

Coverage typically limited to 2 years; annual reauthorization beyond 2 years requires updated serum calcium and evidence patient remains at high fracture risk.

Reauthorization teriparatide: Annual reauthorization beyond 2 years requires updated serum calcium and evidence patient remains at high risk for fracture.

See product guidance.

Tolvaptan (ADPKD vs hyponatremia)

Tolvaptan coverage differs by indication

Tolvaptan for ADPKD: Positive kidney cysts on imaging plus either Mayo Imaging Classification 1C–1E, historical eGFR decline ≥3 mL/min/1.73 m2/year, or PROPKD score >6; submission of serum sodium; prescriber restricted to nephrology; exclusions include significant liver impairment and coadministration with strong CYP3A inhibitors/inducers or desmopressin.Mayo 1C–1E or eGFR decline >=3 mL/min/1.73m2/year

Coverage duration 1 year; ADPKD formulation subject to REMS/distribution program as applicable.

Tolvaptan for hyponatremia: Evidence of clinically significant hyponatremia defined as serum sodium <125 mEq/L OR symptomatic serum sodium <135 mEq/L resistant to fluid restriction; treatment must be initiated in a monitored setting where serum sodium can be closely followed; exclusions include underlying liver disease and coadministration with strong CYP3A inhibitors/inducers or desmopressin.serum sodium <125 or symptomatic <135

Treatment limited to 30 days to reduce risk of liver injury.

Targeted oncology agents

Targeted oncology agents require mutation confirmation and prior therapy documentation where applicable

EGFR-targeted therapy: Submission of test confirming EGFR exon 19 deletions, exon 21 L858R, or T790M mutations as applicable; for T790M‑positive NSCLC, submission of prior EGFR TKI therapy; prescriber restricted to oncology; age ≥18.

Product‑specific prior therapy documentation required.

MET exon 14 agents: Submission of test confirming MET exon 14 skipping mutation; pregnancy status for females of childbearing potential; prescriber restricted to oncology; age ≥18.

Product‑specific exclusions and interaction cautions apply.

FLT3 inhibitor (VANFLYTA): Submission of test confirming FLT3 internal tandem duplication (ITD) mutation; submission of baseline QTcF and serum potassium/magnesium levels; pregnancy status submitted; exclusions include QTcF >450 msec, uncorrected hypokalemia/hypomagnesemia, and coadministration with moderate/strong CYP3A inducers.QTcF <=450 msec at initiation

Prescriber restricted to hematology/oncology; coverage duration 1 year.

Primary IgA nephropathy - Initial Authorization

Covered when ALL of the following are met for primary IgA nephropathy:

IgA nephropathy initial authorization: Diagnosis of primary IgA nephropathy confirmed by renal biopsy.

Proteinuria requirement: 24‑hour urine protein ≥0.5 g/day OR 24‑hour UPCR ≥0.8 g/g.24‑hour urine protein >=0.5 g/day OR UPCR >=0.8 g/g

Safety labs: Submission of liver function testing or Child‑Pugh score.

Pregnancy status for females of childbearing potential submitted.

ACEi/ARB prerequisite: Patient is currently using, or has intolerance/contraindication to, a maximally‑tolerated dose of an ACE inhibitor or ARB prior to initiation.

Annual reauthorization requires documentation of stabilization or improvement of UPCR.

Verquvo (vericiguat) - Initial Authorization

Covered when ALL of the following are met for vericiguat in HFrEF:

HFrEF diagnosis and recent decompensation: Diagnosis of heart failure with reduced ejection fraction and recent decompensation documented by hospitalization for HFrEF within the prior 6 months OR outpatient IV diuretic within the prior 3 months.

LVEF: Left ventricular ejection fraction <45% as documented by imaging.<45%

Background therapy: Patient is on guideline‑directed background therapy: ACE inhibitor or ARB or sacubitril/valsartan AND a beta‑blocker AND a mineralocorticoid receptor antagonist at maximally‑tolerated doses, or documentation explaining why not.

Prescriber restriction to cardiology typically applies; documentation of prior therapies required.

Exclusions: Not pregnant and not receiving concomitant soluble guanylate cyclase stimulators or phosphodiesterase‑5 inhibitors.

Coverage duration 1 year.

Rifaximin (Xifaxan) - Indication-specific criteria

Rifaximin coverage by indication:

Hepatic encephalopathy (HE): Diagnosis of hepatic encephalopathy with prior failure or intolerance to lactulose; coverage duration 1 year.

Prescriber restricted to gastroenterology/hepatology.

IBS-D: Diagnosis of IBS‑D with documentation of failure of at least two prior medication classes (e.g., antidiarrheals, antispasmodics, tricyclic antidepressants) and documentation of number of prior 14‑day rifaximin courses in lifetime; approved duration 14 days with a maximum of 3 lifetime 14‑day courses.max 3 lifetime 14‑day courses

Prescriber restricted to gastroenterology/hepatology.

SIBO: Positive carbohydrate breath test confirming SIBO AND documentation of prior antibiotic trials and prior rifaximin courses in the previous 365 days; approved duration 14 days with a maximum of 2 courses per 365 days.max 2 14‑day courses per 365 days

Prescriber restricted to gastroenterology/hepatology.

Vitrakvi (larotrectinib) - Coverage criteria

TRK inhibitor coverage (Vitrakvi):

NTRK fusion: Submission of evidence of an NTRK gene fusion without a known acquired resistance mutation.

Disease status: Attestation that tumor is metastatic or that surgical resection and other systemic therapies are unsatisfactory treatment options.

Prescriber restricted to oncology; coverage duration 1 year.

Multiple myeloma — prior therapy criteria

Products with specified prior therapy and documentation requirements are covered when ALL of the following are met:

Multiple myeloma combos: Diagnosis of the indicated multiple myeloma use; submission of pregnancy status for females of childbearing potential; for combinations with bortezomib and dexamethasone document failure of at least one previous therapy; for relapsed/refractory multiple myeloma document failure of at least four prior lines of systemic therapy including ≥2 proteasome inhibitors, ≥2 immunomodulatory agents, and an anti‑CD38 monoclonal antibody where specified.as stated

Prescriber restricted to hematology/oncology; coverage duration 1 year.

Ovarian cancer — platinum response and BRCA testing

Oncology product coverage when ALL of the following are met:

Recurrent epithelial ovarian (gBRCA): Diagnosis of covered use; submission of pregnancy status for females of childbearing potential; documentation of response to platinum‑based chemotherapy where required; for germline BRCA‑mutated recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer submission of test confirming presence of a deleterious BRCA mutation.as stated

Prescriber restricted to oncology; coverage duration 1 year.

Postpartum depression — limited duration

Products with short-course limits or postpartum indications:

Postpartum depression product: Diagnosis of postpartum depression and attestation patient is within 12 months postpartum; prescriber specialty restricted to gynecology/obstetrics or psychiatry; age ≥18; coverage duration limited to 14 days; only one 14‑day course allowed per plan year owing to limited safety/efficacy data beyond one course.within 12 months postpartum

Coadministration exclusions (e.g., strong CYP3A4 inducers) must be absent.

Reauthorization monitoring

Monitoring and reauthorization requirements:

XURIDEN reauthorization: For annual reauthorization, submit documentation demonstrating improvement or stabilization of urine orotic acid level, neutrophil count, and mean corpuscular volume as applicable to the treated condition.as stated

Prescriber and lab submissions per product guidance required.

Coverage for Besremi will be excluded when the patient has a history or current presence of serious psychiatric conditions or other listed high-risk comorbidities. Specifically, approvals are not permitted for patients with severe active central nervous system lupus or those currently receiving other biologic therapies or intravenous cyclophosphamide. Coverage also excludes patients with moderate to severe hepatic impairment (Child-Pugh B or C), immunosuppressed transplant recipients, unstable cardiovascular disease, recent stroke or myocardial infarction within 6 months, and severe renal impairment. Providers must submit the diagnosis and current therapies; annual reauthorization requires confirmation the patient remains on some form of standard therapy unless contraindicated.

Ayvakit (avapritinib) is excluded when given with moderate or strong CYP3A inducers or strong CYP3A inhibitors. For advanced or indolent systemic mastocytosis, requests are excluded if the patient’s platelet count is 50 x 10^9/L. Prior to approval, providers must submit the diagnosis and pregnancy status for females of childbearing potential; for GIST indications a PDGFRA exon 18 mutation test result is required. Age and prescriber limits apply (age ≥18; prescribers restricted to allergy, hematology, immunology, and oncology).

CABOMETYX and similar targeted kinase agents list severe hepatic impairment and uncontrolled hypertension among exclusion criteria. Product-specific exclusions vary but commonly include significant liver dysfunction and clinically unstable cardiovascular conditions; providers must submit baseline blood pressure and pregnancy status where applicable and confirm prior therapies as required by the specific product entry.

Several agents with known QT-prolonging potential are exclusionary for patients with congenital long QT syndrome, history of torsades de pointes, or elevated QT intervals at baseline. For example, CAPRELSA-related entries exclude congenital long QT syndrome and torsades; other oncology agents require a baseline QTcF threshold (commonly >450 msec or other drug-specific thresholds) to be absent before approval. Submission of ECG/QTcF and electrolyte levels is required when QT risk is present.

Use of GLP-1 receptor agonists for the purpose of weight management is excluded from coverage. The policy explicitly states these products will not be approved for off-label weight management under Medicare Part D; approvals are limited to FDA‑approved indications with required diagnostic documentation.

Requests for prophylactic hereditary angioedema (HAE) therapy are excluded in certain circumstances per product-specific language. For HAE therapies, the policy distinguishes prophylactic versus acute treatment and requires objective documentation that prophylactic therapy is medically necessary (disease activity, attack frequency, and impact on quality of life) before authorizing prophylactic use.

Pregnancy is an explicit exclusion for select agents. The policy lists pregnancy as an exclusionary condition for products such as ERIVEDGE; providers must submit pregnancy status for females of childbearing potential and coverage will not be authorized when pregnancy is present.

Product Codes, Numeric Thresholds, and Key Clinical Metrics

Product strengths/packagingmixed

50-75 & 150 MG, 50-25-37.5 & 75 MG

TRIKAFTA ORAL THERAPY PACK

Product strengthsmixed

140 MG/ML, 70 MG/ML	AIMOVIG SUBCUTANEOUS SOLUTION AUTOINJECTOR
300 MG DOSE	EMGALITY 300 MG DOSE

Listed product-dose entries (example)mixed

LENVIMA (4 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (8 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (10 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (12 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (14 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (18 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (20 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (24 MG DAILY DOSE)	LENVIMA product/dose listed

LORBRENAmixedCovered

LORBRENA ORAL TABLET 100 MG	LORBRENA 100 mg tablet
LORBRENA ORAL TABLET 25 MG	LORBRENA 25 mg tablet

LYTGOBI dosage entriesmixedCovered

LYTGOBI (12 MG DAILY DOSE)	LYTGOBI product/dose
LYTGOBI (16 MG DAILY DOSE)	LYTGOBI product/dose
LYTGOBI (20 MG DAILY DOSE)	LYTGOBI product/dose

No explicit CPT/HCPCS/NDC codes present in this sectionmixed

No codes listed

No explicit CPT/HCPCS/NDC codes listedmixed

No codes listed

inv-89: Pulmonary arterial pressure — > 20 mm Hg

Threshold> 20 mm Hg

ContextMean pulmonary arterial pressure at rest used to confirm pulmonary arterial hypertension (right heart catheterization required).

Associated criteriaUsed with PAWP ≤15 mm Hg and PVR >2 Wood units for WHO Group 1 PAH documentation.

inv-90: Pulmonary arterial wedge pressure — ≤ 15 mm Hg

Threshold≤ 15 mm Hg

ContextPulmonary arterial wedge pressure (PAWP) from right heart catheterization used to distinguish pre-capillary PAH.

Associated criteriaMust be documented alongside mean pulmonary arterial pressure >20 mm Hg for PAH diagnosis.

inv-91: Pulmonary vascular resistance (PAH, WHO Group 1) — > 2 Wood units

Threshold> 2 Wood units

ContextPulmonary vascular resistance (PVR) requirement for WHO Group 1 (PAH) on right heart catheterization.

Related documentationPVR >2 Wood units must be submitted for WHO Group 1 and prior therapy/trial documentation required.

inv-92: Pulmonary vascular resistance (CTEPH, WHO Group 4) — > 3 Wood units

Threshold> 3 Wood units

ContextPulmonary vascular resistance threshold specified for chronic thromboembolic pulmonary hypertension (CTEPH, WHO Group 4).

DocumentationCTEPH requires evidence of chronic pulmonary embolism on CT or V/Q scan and PVR >3 Wood units.

inv-93: Platelet count threshold for AYVAKIT (advanced/indolent systemic mastocytosis) — < 50 x 10^9/L (exclusion if below)

Threshold< 50 x 10^9/L (exclusion if below)

ContextFor systemic mastocytosis indications (AYVAKIT) a platelet count below this value is exclusionary.

Provider requirementSubmit platelet count as part of prior authorization; prescriber specialty restrictions apply.

inv-94: LV outflow tract obstruction gradient — >= 50 mm Hg

Threshold>= 50 mm Hg

ContextLeft ventricular outflow tract (LVOT) obstruction gradient required for mavacamten initial authorization (rest, Valsalva, or post-exercise).

Associated requirementsMust also document exertional NYHA II–III symptoms and LV wall thickness criteria; prescriber restricted to cardiology.

inv-95: LV wall thickness — >= 15 mm or >= 13 mm if familial

Threshold>= 15 mm or >= 13 mm if familial

ContextLeft ventricular wall thickness criterion for mavacamten (>=15 mm; >=13 mm when familial hypertrophic cardiomyopathy).

Additional infoSubmission of current LVEF required; age ≥18 and cardiology prescriber restriction apply.

inv-96: Digoxin PA age threshold — PA applies to patients 65 years of age or older

ThresholdPA applies to patients 65 years of age or older

ContextPrior authorization requirement for digoxin applies to patients aged 65 and older; does not apply to patients 64 or younger.

ExceptionsPA not required for cardiology prescribers or doses ≤0.125 mg/day.

inv-97: Platelet count threshold (procedure) — < 50 x 10^9/L for chronic liver disease patients undergoing procedure

Threshold< 50 x 10^9/L for chronic liver disease patients undergoing procedure

ContextDOPTELET use for procedure-related thrombocytopenia requires platelet count below 50 x10^9/L for chronic liver disease patients scheduled for a procedure.

DurationCoverage duration for procedure indication: 5 days.

inv-98: Platelet count threshold (ITP) — < 30 x 10^9/L or < 50 x 10^9/L with symptomatic bleeding

Threshold< 30 x 10^9/L or < 50 x 10^9/L with symptomatic bleeding

ContextITP initial authorization requires platelet count <30 x10^9/L, or <50 x10^9/L when symptomatic bleeding is present; prior failure of ≥2 ITP therapies required.

Reauthorization metricFirst reauthorization for ITP requires platelet improvement ≥50 x10^9/L after ≥4 weeks on max tolerated dose.

inv-99: mMRC dyspnea scale — >= 2

Threshold>= 2

DefinitionmMRC (modified Medical Research Council) dyspnea scale score used to define symptomatic COPD for biologic authorization.

ContextMust be met alongside stable triple inhaler therapy requirement for COPD initial authorization.

inv-100: COPD Assessment Test (CAT) — >= 10

Threshold>= 10

DefinitionCOPD Assessment Test (CAT) score used to define symptomatic COPD for biologic authorization.

ContextEither mMRC ≥2 OR CAT ≥10 required along with stable ICS+LABA+LAMA therapy for COPD initial authorization.

inv-101: Eosinophils on esophageal biopsy — >= 15 eos/hpf or 60 eos/mm2

Threshold>= 15 eos/hpf or 60 eos/mm2

ContextUpper endoscopy with biopsy showing this density of eosinophils required to confirm eosinophilic esophagitis (EoE).

Other requirementsDocumentation of symptoms (e.g., dysphagia) and failed 8-week PPI trial required; age ≥11 years.

Prior Authorization, Documentation, Step Therapy, and Denial Triggers

Denial Risk

Authorization requirement

Prior authorization is required for certain Medicare Advantage Part D formulary drugs; listed drugs are marked 'PA' on the formulary. Failure to obtain prior authorization may result in the drug not being covered.

Drugs on the Independent Health Medicare Advantage Part D formulary marked 'PA' require prior authorization.
Contact Medicare Member Services at 1-800-665-1502 (TTY 711) with questions.

Prior Authorization

Biologic group prior authorization and TB screening

Drugs in the biologic/immunomodulatory group generally require baseline latent tuberculosis (PPD or IGRA) screening (except Otezla and Velsipity) and initial authorization commonly requires failure or intolerance to at least two preferred agents as specified.

Baseline TB screening (PPD or IGRA) required for biologic group except Otezla and Velsipity.
Initial authorization usually requires trial/failure or intolerance to ≥2 preferred agents (e.g., adalimumab biosimilar, Cosentyx, Enbrel, Rinvoq, Skyrizi, ustekinumab biosimilar, Xeljanz) where applicable.
If TB test is positive, coverage may be delayed until latent TB is treated; annual re‑screening or chest X‑ray may be required for ongoing therapy if exposure risk exists.

Prior Authorization

Caplacizumab prior authorization and recurrence limit

Caplacizumab prior authorization requires documentation of diagnosis and treatment context; use limits apply for recurrences.

Submit diagnosis of covered use and confirmation drug will be given with plasma exchange and immunosuppressive therapy.
If request is not for first use, submit previous aTTP recurrences while on caplacizumab.
Coverage will not be authorized if the patient has had more than 2 recurrences of aTTP while on therapy.
Coverage Duration: 3 months.

Prior Authorization

CFTR modulators prior authorization and required mutation testing

CFTR modulator (ivacaftor, lumacaftor/ivacaftor, tezacaftor/ivacaftor, elexacaftor/tezacaftor/ivacaftor) prior authorization requires confirmatory CFTR mutation testing per prescribing information.

Submit cystic fibrosis mutation test confirming presence of CFTR gene mutations appropriate for the requested drug: e.g., ivacaftor‑responsive mutation per PI for Kalydeco; F508del homozygous for Orkambi; responsive mutations per PI or in vitro data for Symdeko/Trikafta.
Prescriber restriction: pulmonology.
Coverage Duration: 1 year.

Documentation Required

PA requires diagnosis, prior therapy, and attestation

Prior authorization requests must include diagnosis, prior therapy history, and prescriber attestation of concomitant or continued standard therapies when required.

Document the diagnosis of covered use and submit current or prior therapies used to treat the condition where required.
Provider attestation that background or concomitant standard-of-care therapies will be continued after initiation of the requested agent (e.g., ICS‑LABA‑LAMA for COPD, triple inhaler regimen for asthma) when applicable.
Missing prior therapy or lab documentation is a common denial trigger.

Prior Authorization

Authorization and prior therapy requirements for oncology/specialty agents

Certain oncology and specialty agents require prerequisite therapy or prior targeted agents before approval; documentation of mutation testing or prior lines of therapy is frequently required.

Examples: ICLUSIG requests require documentation of T315I mutation status or resistance/intolerance to ≥2 prior kinase inhibitors for CP‑CML (non‑T315I).
GAVRETO and similar agents require tumor ROS1 or NTRK testing as applicable.
Many agents require documented failure/intolerance to specific prior therapies (e.g., crizotinib or entrectinib before GAVRETO; prior VEGFR inhibitor for FILSPARI).
Prescriber specialty restrictions often apply (oncology, hematology).

Prior Authorization

IMBRUVICA — prior authorization and hepatic/interaction exclusions

IMBRUVICA prior authorization requires hepatic assessment and prior therapy documentation for some indications; several cardiac and drug interaction exclusions apply.

Submit diagnosis and liver function testing or Child‑Pugh score; pregnancy status for females of childbearing potential.
For chronic graft‑versus‑host disease, document treatment failure with another systemic immunosuppressive agent.
Exclusions: severe hepatic impairment (Child‑Pugh class C) and coadministration with strong CYP3A inducers.
Prescriber restriction: hematology, oncology, transplant specialties.

Prior Authorization

ICLUSIG — prior authorization and interaction/exclusion triggers

ICLUSIG prior authorization requires mutation testing, blood pressure monitoring, and exclusion of newly diagnosed CP‑CML without appropriate prior therapy; drug interaction and cardiovascular exclusions apply.

Submit diagnosis and documentation of T315I mutation status (present or absent).
Provide baseline blood pressure reading and pregnancy status for females of childbearing potential.
Exclusions: newly diagnosed CP‑CML, uncontrolled hypertension.
For non‑T315I CP‑CML, document resistance or intolerance to at least two prior kinase inhibitors.
Prescriber restriction: hematology and oncology.

Prior Authorization

LENVIMA — prior authorization and required documentation

LENVIMA prior authorization requires documentation of diagnosis, baseline vitals/labs, pregnancy status, and indication‑specific prior therapies or coadministration attestations.

Submit diagnosis, baseline blood pressure, and pregnancy status for females of childbearing potential.
For thyroid cancer: attest radioactive iodine‑refractory or ineligible.
For renal cell carcinoma: attest coadministration with pembrolizumab or everolimus; if with everolimus, submit prior anti‑angiogenic therapy tried and failed.
Exclusions include uncorrected electrolyte abnormalities and uncontrolled hypertension.
Prescriber restriction: oncology. Coverage Duration: 1 year.

Documentation Required

Part B vs Part D coverage determination

Part B vs Part D coverage depends on intended use and administration setting; provide documentation about how the drug will be used and whether it will be self‑administered or administered in a provider setting.

If medication will be self‑administered after training or the provider agrees to have it filled at a pharmacy and delivered to the office by the patient for provider administration, it may be covered under Part D; otherwise it may be covered under Part B.
Include a description of how the drug will be used/obtained to determine Part B vs Part D coverage.

Prior Authorization

PA and reauthorization requirements

Reauthorization criteria commonly require evidence of clinical benefit or maintenance of previously achieved benefit and ongoing documentation of required background therapies and monitoring.

Reauthorization frequently requires documentation of symptomatic or clinical improvement (or maintenance of prior improvement), objective measures (e.g., labs, FEV1, exacerbation rates), or ongoing use of required background therapy.
Examples: dupilumab reauthorization requires continued use of background therapies and demonstration of benefit for asthma/COPD; QINLOCK reauthorization requires clinically relevant response in 24‑hour UFC for Cushing's syndrome.

Prior Authorization

Prior authorization and coverage duration

Prior authorizations typically specify a coverage duration (commonly 1 year) though some products have different limits (e.g., 12 weeks, 3 months, 30 days).

Common coverage duration for specialty drugs: 1 year.
Exceptions: HCV regimens often 12 weeks; caplacizumab coverage duration 3 months; tolvaptan for hyponatremia limited to 30 days to limit liver injury.
Document duration on the PA request and monitor reauthorization timing.

Prior Authorization

Tolvaptan (hyponatremia) PA rules

Tolvaptan for clinically significant hyponatremia requires initiation in a monitored setting, short‑term use only, and specific laboratory documentation to support the indication.

Submit evidence of clinically significant hyponatremia: serum sodium <125 mEq/L or symptomatic serum sodium <135 mEq/L resistant to fluid restriction.
Treatment must be initiated in a setting where serum sodium can be closely monitored.
Coverage is limited to 30 days to prevent liver injury; this formulation is not approved for ADPKD under this policy.

Documentation Required

General prior authorization requirements

General prior authorization requirements: submit diagnosis, relevant baseline labs, pregnancy status for females of childbearing potential, prescriber specialty, and prior therapy history when applicable.

Common baseline labs: liver function tests/Child‑Pugh, serum transaminases, bilirubin, ALP, CBC with differential, serum potassium and magnesium, ECG/QTc (or QTcF) when QT‑prolonging risk exists.
Provide pregnancy status for females of childbearing potential.
Attach documentation of prior therapies and line/step therapy trials when required; missing labs or prior therapy documentation can trigger denial.

Prior Authorization

Verquvo prior authorization requirements

Verquvo (vericiguat) prior authorization requires documentation of recent HF hospitalization or IV diuretic use, reduced LVEF, and prior therapies for HFrEF.

Submit diagnosis including either hospitalization for HFrEF within previous 6 months or outpatient IV diuretic use within previous 3 months.
Provide left ventricular ejection fraction (<45%) and pregnancy status for females of childbearing potential.
Submit current or previous therapies used to treat HFrEF; prescriber restriction: cardiology.

Denial Risk

Exclusion criteria and denial triggers (drug interactions, hepatic, cardiac, electrolyte, pregnancy, cosmetic)

Certain products have specific exclusion triggers such as drug interactions, hepatic impairment, QT prolongation risk, electrolyte abnormalities, pregnancy, or age limits; presence of exclusions may result in denial.

Drug interaction exclusions: examples include prohibition of moderate/strong CYP3A inhibitors/inducers with ICLUSIG, GAVRETO, VANFLYTA, and others; proton pump inhibitors/H2 antagonists exclude some agents (e.g., certain TKIs).
Hepatic exclusions: severe hepatic impairment (Child‑Pugh C) excludes many agents (IMBRUVICA, Trikafta severe hepatic impairment, others).
Cardiac/QT exclusions: baseline QTc >450–470 msec depending on product, congenital long QT, history of torsades de pointes; require baseline ECG/QTcF and electrolytes (K+, Mg2+).
Electrolyte and hematologic exclusions: uncorrected hypokalemia/hypomagnesemia, neutropenia thresholds, platelet/ANC minima for some therapies.
Pregnancy and reproductive status: many agents require pregnancy status; teratogenic agents require negative pregnancy testing and counseling.
Age and indication‑specific exclusions may apply; cosmetic uses (e.g., topical retinoids for cosmetic indications) are excluded.

Documentation Required

Required diagnostic and laboratory documentation; missing tests cause denials

Submit required diagnostic testing and objective disease measures when indicated (genetic/tumor testing, pulmonary hemodynamics, microbiology, ECGs, and key labs). Missing required tests is a frequent cause for denial.

PAH: submit right heart catheterization results, WHO Group classification, mean pulmonary arterial pressure >20 mm Hg, PAWP ≤15 mm Hg, PVR thresholds, creatinine clearance, and pregnancy status.
MAC lung disease (e.g., ARIKAYCE): document multi‑drug MAC regimen tried and failed for ≥6 months and positive sputum culture obtained after treatment.
Cardiac/QT‑risk drugs: submit ECG/QTcF, serum potassium, and serum magnesium.
Oncology/targeted therapies: submit tumor mutation testing (ALK, ROS1, NTRK, BRCA, IDH2, FGFR, RET, etc.) and prior lines/agents used.
Dupilumab: submit diagnosis and current background therapy and provider attestation that background therapy will continue where required.

Step Therapy

Prior therapy, step therapy, and course limits

Some drugs and indications require specific prerequisite or step therapy trials and documented failure/intolerance to alternative agents before approval; ensure documentation of duration and outcome of prior trials.

Examples: AUVELITY requires failure of standard therapies prior to approval; Opsumit initial authorization requires prior failure/intolerance to ambrisentan or bosentan.
PCSK9 inhibitors (Repatha) typically require ≥8 weeks of high‑intensity statin therapy with inadequate LDL response, or documented statin intolerance or rhabdomyolysis.
Oncology agents frequently require prior chemotherapy lines or specific prior targeted therapy as detailed per drug entry.
Document trial durations (e.g., MAC regimen ≥6 months) and reasons for discontinuation (intolerance, lack of efficacy).

Initial Authorization / Step Therapy Requirements

Requirement	Example documentation
Documentation that patient has used prior statin therapy (or current statin use unless contraindicated)	Medication history showing statin name, dose, duration; evidence of intolerance or inadequate LDL response
If applicable, documentation of prior statin trials including at least one hydrophilic statin previously tried and failed	Clinical notes or lab results showing LDL levels before and after statin therapy or notes explaining intolerance (e.g., rhabdomyolysis)

Required before initial authorization of CAMZYOS	Documentation/examples
Trial and inadequate response or intolerance to both a beta-blocker and a non‑DHP calcium channel blocker	Provider attestation that both classes were tried and patient had inadequate response or intolerance
Clinical medication list showing agents, doses, and treatment dates for beta‑blocker and non‑DHP CCB trials	Cardiology evaluation documenting persistent NYHA II–III symptoms despite trials; echocardiogram or hemodynamic data confirming LVOT gradient and LV wall thickness per criteria

Emgality prevention step	Example documentation
Trial and inadequate response or intolerance to Aimovig (erenumab) prior to Emgality for migraine prevention	Statement that Aimovig was tried and failed or was contraindicated
Medication history showing Aimovig prescription dates and reason for discontinuation (lack of efficacy or adverse events)	Baseline headache days per month from chart and documentation of lack of improvement on Aimovig

Reauthorization and Monitoring Requirements

Step and Failure Requirements

Step therapy — prior trials required	Documentation/examples
For ITP: documentation of failure of at least two ITP therapies from different classes prior to DOPTELET (e.g., systemic corticosteroids, IVIG, danazol, fostamatinib, cytotoxics/immunosuppressants)	Submission of current platelet counts meeting threshold criteria per indication
Medication records showing prior ITP therapies tried, dates, doses, and reasons for discontinuation or lack of efficacy	Laboratory results showing platelet counts before and after prior therapies and at time of request

Step therapy — CAMZYOS prerequisite	Documentation/examples
Trial and inadequate response or intolerance to both a beta‑blocker and a non‑DHP calcium channel blocker prior to mavacamten initiation	Provider attestation that both classes were used and were ineffective or not tolerated
Medication history listing specific beta‑blocker and non‑DHP CCB agents, doses, treatment duration, and reason for discontinuation	Cardiology assessment documenting symptomatic NYHA II–III status and supporting echocardiographic measurements (LVOT gradient, LV wall thickness) per CAMZYOS criteria

Emgality step requirement — migraine prevention	Required documentation
Documentation Aimovig (erenumab) was tried and had inadequate response before Emgality for prevention	If Aimovig contraindicated, clinical rationale for contraindication must be provided
Medication history showing Aimovig treatment dates and clinical response; headache diary or charted headache days per month pre‑ and on‑therapy	For first reauthorization: on‑treatment headache days demonstrating improvement from baseline

DOPTELET step requirement — ITP prior trials	Required documentation examples
Failure of at least two ITP therapies from different classes before initial DOPTELET authorization	Platelet count meeting ITP threshold (<30 x10^9/L or <50 x10^9/L with symptomatic bleeding) documented
Records of prior ITP therapies with dates, doses, and reasons for failure/intolerance (e.g., corticosteroids, IVIG, rituximab)	Platelet count lab reports before and after prior therapies and at request time; splenectomy status if applicable

Oncology & specialty agents — prior trials/failures	Documentation/examples
Documentation of trials and failures or intolerances to specified prior agents or classes as listed in each product section (e.g., prior VEGFR inhibitors, prior chemotherapy regimens, prior ALK/ROS1 inhibitors)	Attestation that listed prior therapies were tried and failed or were contraindicated/intolerable
Oncology med history with regimen names, dates, responses, and reason for discontinuation; pathology/genetic testing confirming target (e.g., ROS1, ALK)	Relevant labs and safety data (e.g., baseline BP, LFTs, Child‑Pugh score) when required per product

Generic step examples — documentation to include	Examples of acceptable evidence
Document prior therapies tried and the specific reason for failure or intolerance where required by policy	Include medication names, doses, start/stop dates, and clinical rationale for switching or stopping therapy
Laboratory data, imaging, or specialist notes supporting lack of efficacy or intolerance (e.g., LDL levels, liver tests, blood counts, ECGs)	For biologics: documentation of trials of preferred on‑formulary alternatives and TB screening or other baseline tests where required

Course Limits and Quantity Restrictions

inv-286: Vowst — 1 course

Quantity limit1 course

DrugVowst

ContextAuthorized quantity limit for Vowst per policy.

inv-287: Xifaxan (rifaximin) for IBS-D — 3

Quantity limit3 (max lifetime 14-day courses)

DrugXifaxan (rifaximin) — IBS-D

ContextDocumentation of number of prior 14-day courses required for authorization.

inv-288: Xifaxan (rifaximin) for SIBO — 2

Quantity limit2 (max 14-day courses per 365 days)

DrugXifaxan (rifaximin) — SIBO

ContextPositive carbohydrate breath test and prior course documentation required for SIBO authorization.

Administration Site, Part B vs Part D, and Initiation Requirements

Note

Policy Background and Scope

This document enumerates the clinical and administrative prerequisites required to obtain prior authorization for prescription drugs on Independent Health’s Medicare Advantage Part D formulary. It summarizes product-specific coverage rules, required diagnostic or laboratory documentation, prescriber restrictions, age limits, prerequisite therapy or step‑therapy requirements, and exclusions (for example, pregnancy, severe hepatic impairment, certain drug–drug interactions, or specified QT/electrolyte abnormalities). Providers must submit the requested objective test results and attestations (e.g., pregnancy status, baseline labs, prior therapy trials, right‑heart catheterization data for PAH, CFTR mutation testing for CFTR modulators, or biopsy results where indicated) when filing a PA; failure to obtain PA or to provide required documentation may result in denial.

inv-239: Coverage Duration — The authorized time period for coverage (commonly 1 year for many listed products; exceptions noted where shorter durations apply).

DefinitionThe authorized time period for coverage (commonly 1 year for many listed products; exceptions noted where shorter durations apply).

Typical duration1 year is the common coverage duration for most specialty drugs in this policy.

ExceptionsSome products have shorter authorized durations (e.g., tolvaptan for hyponatremia limited to 30 days; Vowst limited to 1 course; EoE max 12-week course per 365 days).

Clinical Definitions and Thresholds

inv-222: Baseline latent TB screening — A Mantoux tuberculin skin test (PPD) or interferon-gamma release assay (IGRA) required prior to initiating many biologic/immunomodulatory...

RequirementMantoux PPD or interferon-gamma release assay (IGRA) prior to initiating most biologic/immunomodulatory therapies (except Otezla and Velsipity)

Action on positive resultIf TB screening is positive, coverage is delayed until latent TB is treated.

ReauthorizationYearly TB screening or chest X-ray required for patients with ongoing high TB exposure risk while on treatment.

inv-223: Pulmonary arterial hypertension (PAH) diagnostic thresholds — Documentation includes mean pulmonary arterial pressure >20 mm Hg at rest, pulmonary arterial wedge pressure ≤15 mm Hg, and pulmonary vas...

Mean pulmonary arterial pressure>20 mm Hg at rest

PAWP≤15 mm Hg

PVR>2 Wood units (WHO Group 1) or >3 Wood units for CTEPH)

inv-228: EoE histology threshold — Biopsy showing at least 15 eosinophils per high-power field (or 60 eos/mm2) required for eosinophilic esophagitis.

Threshold>= 15 eos/hpf or 60 eos/mm2

ContextHistologic criterion required on esophageal biopsy to diagnose eosinophilic esophagitis (EoE).

Other requirementsSymptoms consistent with EoE and failed 8-week PPI trial required for authorization.

Document Updates

2026-01-14policy_effectiveLatest

Policy effective date updated to 2026-01-14 for the Independent Health Medicare Advantage Part D prior authorization index and criteria.

Policy Summary

PayerIndependent Health

PolicyPrior Authorization Criteria for Medicare Part D Formulary Drugs

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateJan 14, 2026

Next Review DateN/A

SourceLink

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Prior Authorization Criteria for Medicare Part D Formulary Drugs

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Policy Summary

PayerIndependent Health

PolicyPrior Authorization Criteria for Medicare Part D Formulary Drugs

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateJan 14, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+products shown in this excerpt

1 yeartypical coverage duration

manyrequires prior therapies

frequentdiagnostic testing required

Coverage Criteria and Drug-Specific Authorization Rules

Biologic/immunomodulatory drugs — initial authorization

Covered when ALL of the following are met for biologic/immunomodulatory drugs (except Otezla and Velsipity):

Applies to all drugs managed by this biologic/immunomodulatory group except Otezla and Velsipity; annual TB screening or chest X‑ray may be required for ongoing therapy in patients at risk.

Pulmonary hypertension (PAH) — initial authorization

Covered when ALL of the following are met for pulmonary hypertension agents (example: ADEMPAS):

Prescriber restricted to cardiology or pulmonology; age ≥18; coverage duration 1 year.

ARIKAYCE — initial authorization

Covered when ALL of the following are met for ARIKAYCE (MAC lung disease):

Coverage duration 1 year; ARIKAYCE is not covered for non‑refractory MAC disease.

Caplacizumab — initial authorization

Covered when ALL of the following are met

Prescriber restricted to cardiology, hematology, or immunology; coverage duration 3 months.

Mavacamten (CAMZYOS) — initial authorization

Covered when ALL of the following are met

Prescriber restricted to cardiology; coverage duration 1 year.

CFTR modulators — initial authorization

Covered when ALL of the following are met

Emgality — migraine

Covered when ALL of the following are met

Dupilumab — indication-specific criteria

Covered when ALL of the following are met (indication-specific criteria apply)

dupilumab_general

AD: Atopic dermatitis: objective documentation of ≥10% body surface area involvement AND trial and inadequate response or contraindication to at least a moderate‑strength topical corticosteroid for ≥4 weeks (or documentation why topical steroid is not advisable).4 weeks
Asthma: pre‑bronchodilator FEV1 <80% predicted (adults) or <90% (children) AND either blood eosinophils ≥150 cells/mcL within 6 weeks OR documentation that patient requires daily oral corticosteroid for control; patient must be on GINA‑recommended regimen (maximally‑tolerated ICS + LABA + LAMA) prior to biologic and provider must attest therapy will continue after starting dupilumab.FEV1 and eosinophil thresholds per node
Reauthorization requires continued background therapy and evidence of benefit.
COPD: post‑bronchodilator FEV1/FVC <0.7 and post‑bronchodilator FEV1 30–80% predicted AND blood eosinophils ≥300 cells/mcL within 6 weeks AND symptomatic disease defined by mMRC ≥2 OR CAT ≥10; must be on stable ICS+LABA+LAMA for ≥90 days pre‑initiation and provider must attest therapy will continue.>=90 days; mMRC >=2 OR CAT >=10
Reauthorization requires maintenance of benefit and continued triple therapy.
CRSwNP: Chronic rhinosinusitis with nasal polyps: evidence of nasal polyps and symptomatic nasal congestion AND trial of intranasal corticosteroid for ≥2 months (or contraindication) with provider attestation intranasal steroid will continue after starting dupilumab.2 months
Reauthorization requires documentation of clinical benefit or maintenance.
EoE: Eosinophilic esophagitis: upper endoscopy with biopsy showing ≥15 eos/hpf or 60 eos/mm2 AND documentation of signs/symptoms (e.g., dysphagia) AND failure of an 8‑week PPI trial.>=15 eos/hpf; failed 8‑week PPI
Reauthorization requires documentation of clinical benefit.
PN: Prurigo nodularis: pruritus ≥6 weeks and presence of multiple pruriginous firm nodular lesions with documentation of prior therapies tried; reauthorization requires documentation of clinical benefit.6 weeks

DOPTELET — indications and requirements

Covered when ALL of the following are met

Prescriber specialties limited to gastroenterology, hematology, hepatology, surgery; coverage duration varies by indication.

Initial authorization — Atopic dermatitis (AD)

Covered when ALL of the following are met for indication-specific initial authorization (examples provided):

Provider must document prior topical therapy or contraindication.

Initial authorization — Asthma

Covered when ALL of the following are met for asthma initial authorization:

Provider attestation required; reauthorization requires documentation of clinical benefit or maintenance.

Initial authorization — COPD

Covered when ALL of the following are met for COPD initial authorization:

Both medication stability and symptom threshold required; prescriber specialty as listed per product.

Initial authorization — CRSwNP

Covered when ALL of the following are met for chronic rhinosinusitis with nasal polyps (CRSwNP) initial authorization:

Prescriber specialty restrictions apply; reauthorization requires documentation of clinical benefit or maintenance.

Reauthorization criteria

For reauthorization of chronic conditions (examples):

Required at each reauthorization; prescriber must submit objective measures per product guidance.

Required at each reauthorization.

AD/PN reauthorization: Documentation of clinical benefit such as reduction in itch severity or proportion of body affected, or maintenance of previously achieved benefit.

Required at each reauthorization.

EoE reauthorization: Documentation of clinical benefit such as histologic remission or reduction in dysphagia, or maintenance of previously achieved benefit.

Required at each reauthorization.

Eltrombopag (examples)

Covered when ALL of the following are met for eltrombopag indications (examples):

Initial authorization 12 weeks then 1 year; prescriber specialties restricted to gastroenterology/hematology/hepatology/infectious disease as applicable.

Chronic HCV thrombocytopenia: Platelet count <75 x10^9/L and attestation patient will receive interferon therapy to treat HCV.<75 x10^9/L

Coverage duration 1 year.

Aplastic anemia: Platelet count <30 x10^9/L and submission of planned concomitant immunosuppressive therapy or documentation of refractory disease after prior therapies.<30 x10^9/L

Coverage duration 6 months as specified.

Eosinophilic esophagitis

Covered when ALL of the following are met for eosinophilic esophagitis:

Age ≥11 years; coverage duration 12 weeks with a maximum of one 12‑week course per 365 days.

ALK-positive oncology agents

Covered when ALL of the following are met for ALK-positive oncology agent initial authorization:

Prescriber restricted to oncology; age ≥18; exclusion criteria (e.g., severe hepatic impairment, interacting drugs) absent.

FILSPARI — primary IgA nephropathy

Covered when ALL of the following are met for FILSPARI (IgA nephropathy):

Prescriber restricted to immunology or nephrology; annual reauthorization requires documentation of response (stabilization or improvement of UPCR); coverage duration 1 year.

Oncology prior therapy requirements

Covered when ALL of the following are met for specified oncology agents:

Prescriber restricted to oncology; age ≥18; coverage duration 1 year.

Product-specific authorization criteria (summary)

Covered when ALL of the following product-specific conditions are met (per product):

Product‑specific prior therapy, laboratory, or mutation requirements must also be met as detailed in each product entry.

LENVIMA coverage criteria

Covered when PA criteria for the specific drug are satisfied with required documentation and absence of exclusions

Adhere to product exclusions such as pregnancy; prior therapy prerequisites apply per indication.

LYNPARZA coverage criteria

LYNPARZA coverage requires specific genetic testing and prior therapy attestations depending on indication

Genetic/tumor testing must be submitted per indication.

NUCALA coverage criteria (asthma, CRSwNP, EGPA, HES)

NUCALA covered when clinical and laboratory criteria are met for the specific eosinophilic conditions

LORBRENA coverage criteria

Covered when PA criteria for the specific drug are satisfied with required documentation and absence of exclusions

Adhere to product‑specific exclusions and prior therapy requirements where applicable.

Example: Nuedexta initial and reauthorization criteria

Covered when ALL of the following are met for drugs with QT risk (example: NUEDEXTA):

Coverage duration 1 year; annual reauthorization requires updated potassium/magnesium and documentation of symptomatic or maintained improvement.

Targeted oncology therapy criteria

Covered for targeted oncology agents when ALL of the following apply:

Coverage duration generally 1 year; product‑specific testing and prior therapy requirements must be provided.

Prolastin-C criteria

Covered for Prolastin-C when ALL of the following are met:

Reauthorization requires confirmation of symptomatic or clinical improvement or maintenance; Part B vs Part D determination may apply depending on administration setting; coverage duration 1 year.

Pulmonary arterial hypertension agents - initial authorization

Covered when ALL of the following are met (example: pulmonary arterial hypertension agents)

Coverage duration 1 year; includes product‑specific hepatic/renal exclusions as applicable.

Cushing's syndrome agents - initial and reauthorization

Covered when ALL of the following are met (example: agents for Cushing's syndrome)

Coverage duration 1 year; exclusion for baseline AST/ALT >3× ULN or prolonged QTcF >470 msec; reauthorization requires documentation of clinically relevant response or maintenance.

Oncology targeted therapies - diagnostic confirmation required

Covered when ALL of the following are met (oncology targeted therapies)

Excludes uncontrolled hypertension and coadministration with moderate/strong CYP3A inducers where specified.

Excludes coadministration with moderate/strong CYP3A inducers or QT‑prolonging drugs as specified.

PCSK9 inhibitors - Repatha

Covered when ALL of the following are met (PCSK9 inhibitors example)

Coverage duration 1 year; prior therapy documentation required per indication.

Reauthorization and monitoring requirements

Reauthorization requires demonstration of ongoing benefit for several agents

Applies to agents treating fibrosis/NASH per product entry.

Prescriber restricted to endocrinology.

Drug-specific medical necessity requirements (aggregate)

Covered when all specified drug-specific requirements are met (diagnosis, required testing, prescriber restriction, and absence of listed exclusions).

Apply product‑level details found in each product’s section (chunks referenced).

Teriparatide criteria

Teriparatide (subcutaneous pen-injector) initial and reauthorization criteria

Coverage typically limited to 2 years; annual reauthorization beyond 2 years requires updated serum calcium and evidence patient remains at high fracture risk.

Reauthorization teriparatide: Annual reauthorization beyond 2 years requires updated serum calcium and evidence patient remains at high risk for fracture.

See product guidance.

Tolvaptan (ADPKD vs hyponatremia)

Tolvaptan coverage differs by indication

Coverage duration 1 year; ADPKD formulation subject to REMS/distribution program as applicable.

Treatment limited to 30 days to reduce risk of liver injury.

Targeted oncology agents

Targeted oncology agents require mutation confirmation and prior therapy documentation where applicable

Product‑specific prior therapy documentation required.

MET exon 14 agents: Submission of test confirming MET exon 14 skipping mutation; pregnancy status for females of childbearing potential; prescriber restricted to oncology; age ≥18.

Product‑specific exclusions and interaction cautions apply.

Prescriber restricted to hematology/oncology; coverage duration 1 year.

Primary IgA nephropathy - Initial Authorization

Covered when ALL of the following are met for primary IgA nephropathy:

IgA nephropathy initial authorization: Diagnosis of primary IgA nephropathy confirmed by renal biopsy.

Proteinuria requirement: 24‑hour urine protein ≥0.5 g/day OR 24‑hour UPCR ≥0.8 g/g.24‑hour urine protein >=0.5 g/day OR UPCR >=0.8 g/g

Safety labs: Submission of liver function testing or Child‑Pugh score.

Pregnancy status for females of childbearing potential submitted.

ACEi/ARB prerequisite: Patient is currently using, or has intolerance/contraindication to, a maximally‑tolerated dose of an ACE inhibitor or ARB prior to initiation.

Annual reauthorization requires documentation of stabilization or improvement of UPCR.

Verquvo (vericiguat) - Initial Authorization

Covered when ALL of the following are met for vericiguat in HFrEF:

LVEF: Left ventricular ejection fraction <45% as documented by imaging.<45%

Prescriber restriction to cardiology typically applies; documentation of prior therapies required.

Exclusions: Not pregnant and not receiving concomitant soluble guanylate cyclase stimulators or phosphodiesterase‑5 inhibitors.

Coverage duration 1 year.

Rifaximin (Xifaxan) - Indication-specific criteria

Rifaximin coverage by indication:

Hepatic encephalopathy (HE): Diagnosis of hepatic encephalopathy with prior failure or intolerance to lactulose; coverage duration 1 year.

Prescriber restricted to gastroenterology/hepatology.

Vitrakvi (larotrectinib) - Coverage criteria

TRK inhibitor coverage (Vitrakvi):

NTRK fusion: Submission of evidence of an NTRK gene fusion without a known acquired resistance mutation.

Disease status: Attestation that tumor is metastatic or that surgical resection and other systemic therapies are unsatisfactory treatment options.

Prescriber restricted to oncology; coverage duration 1 year.

Multiple myeloma — prior therapy criteria

Products with specified prior therapy and documentation requirements are covered when ALL of the following are met:

Prescriber restricted to hematology/oncology; coverage duration 1 year.

Ovarian cancer — platinum response and BRCA testing

Oncology product coverage when ALL of the following are met:

Prescriber restricted to oncology; coverage duration 1 year.

Postpartum depression — limited duration

Products with short-course limits or postpartum indications:

Coadministration exclusions (e.g., strong CYP3A4 inducers) must be absent.

Reauthorization monitoring

Monitoring and reauthorization requirements:

Prescriber and lab submissions per product guidance required.

Product Codes, Numeric Thresholds, and Key Clinical Metrics

Product strengths/packagingmixed

50-75 & 150 MG, 50-25-37.5 & 75 MG

TRIKAFTA ORAL THERAPY PACK

Product strengthsmixed

140 MG/ML, 70 MG/ML	AIMOVIG SUBCUTANEOUS SOLUTION AUTOINJECTOR
300 MG DOSE	EMGALITY 300 MG DOSE

Listed product-dose entries (example)mixed

LENVIMA (4 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (8 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (10 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (12 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (14 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (18 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (20 MG DAILY DOSE)	LENVIMA product/dose listed
LENVIMA (24 MG DAILY DOSE)	LENVIMA product/dose listed

LORBRENAmixedCovered

LORBRENA ORAL TABLET 100 MG	LORBRENA 100 mg tablet
LORBRENA ORAL TABLET 25 MG	LORBRENA 25 mg tablet

LYTGOBI dosage entriesmixedCovered

LYTGOBI (12 MG DAILY DOSE)	LYTGOBI product/dose
LYTGOBI (16 MG DAILY DOSE)	LYTGOBI product/dose
LYTGOBI (20 MG DAILY DOSE)	LYTGOBI product/dose

No explicit CPT/HCPCS/NDC codes present in this sectionmixed

No codes listed

No explicit CPT/HCPCS/NDC codes listedmixed

No codes listed

inv-89: Pulmonary arterial pressure — > 20 mm Hg

Threshold> 20 mm Hg

ContextMean pulmonary arterial pressure at rest used to confirm pulmonary arterial hypertension (right heart catheterization required).

Associated criteriaUsed with PAWP ≤15 mm Hg and PVR >2 Wood units for WHO Group 1 PAH documentation.

inv-90: Pulmonary arterial wedge pressure — ≤ 15 mm Hg

Threshold≤ 15 mm Hg

ContextPulmonary arterial wedge pressure (PAWP) from right heart catheterization used to distinguish pre-capillary PAH.

Associated criteriaMust be documented alongside mean pulmonary arterial pressure >20 mm Hg for PAH diagnosis.

inv-91: Pulmonary vascular resistance (PAH, WHO Group 1) — > 2 Wood units

Threshold> 2 Wood units

ContextPulmonary vascular resistance (PVR) requirement for WHO Group 1 (PAH) on right heart catheterization.

Related documentationPVR >2 Wood units must be submitted for WHO Group 1 and prior therapy/trial documentation required.

inv-92: Pulmonary vascular resistance (CTEPH, WHO Group 4) — > 3 Wood units

Threshold> 3 Wood units

ContextPulmonary vascular resistance threshold specified for chronic thromboembolic pulmonary hypertension (CTEPH, WHO Group 4).

DocumentationCTEPH requires evidence of chronic pulmonary embolism on CT or V/Q scan and PVR >3 Wood units.

inv-93: Platelet count threshold for AYVAKIT (advanced/indolent systemic mastocytosis) — < 50 x 10^9/L (exclusion if below)

Threshold< 50 x 10^9/L (exclusion if below)

ContextFor systemic mastocytosis indications (AYVAKIT) a platelet count below this value is exclusionary.

Provider requirementSubmit platelet count as part of prior authorization; prescriber specialty restrictions apply.

inv-94: LV outflow tract obstruction gradient — >= 50 mm Hg

Threshold>= 50 mm Hg

ContextLeft ventricular outflow tract (LVOT) obstruction gradient required for mavacamten initial authorization (rest, Valsalva, or post-exercise).

Associated requirementsMust also document exertional NYHA II–III symptoms and LV wall thickness criteria; prescriber restricted to cardiology.

inv-95: LV wall thickness — >= 15 mm or >= 13 mm if familial

Threshold>= 15 mm or >= 13 mm if familial

ContextLeft ventricular wall thickness criterion for mavacamten (>=15 mm; >=13 mm when familial hypertrophic cardiomyopathy).

Additional infoSubmission of current LVEF required; age ≥18 and cardiology prescriber restriction apply.

inv-96: Digoxin PA age threshold — PA applies to patients 65 years of age or older

ThresholdPA applies to patients 65 years of age or older

ContextPrior authorization requirement for digoxin applies to patients aged 65 and older; does not apply to patients 64 or younger.

ExceptionsPA not required for cardiology prescribers or doses ≤0.125 mg/day.

inv-97: Platelet count threshold (procedure) — < 50 x 10^9/L for chronic liver disease patients undergoing procedure

Threshold< 50 x 10^9/L for chronic liver disease patients undergoing procedure

ContextDOPTELET use for procedure-related thrombocytopenia requires platelet count below 50 x10^9/L for chronic liver disease patients scheduled for a procedure.

DurationCoverage duration for procedure indication: 5 days.

inv-98: Platelet count threshold (ITP) — < 30 x 10^9/L or < 50 x 10^9/L with symptomatic bleeding

Threshold< 30 x 10^9/L or < 50 x 10^9/L with symptomatic bleeding

ContextITP initial authorization requires platelet count <30 x10^9/L, or <50 x10^9/L when symptomatic bleeding is present; prior failure of ≥2 ITP therapies required.

Reauthorization metricFirst reauthorization for ITP requires platelet improvement ≥50 x10^9/L after ≥4 weeks on max tolerated dose.

inv-99: mMRC dyspnea scale — >= 2

Threshold>= 2

DefinitionmMRC (modified Medical Research Council) dyspnea scale score used to define symptomatic COPD for biologic authorization.

ContextMust be met alongside stable triple inhaler therapy requirement for COPD initial authorization.

inv-100: COPD Assessment Test (CAT) — >= 10

Threshold>= 10

DefinitionCOPD Assessment Test (CAT) score used to define symptomatic COPD for biologic authorization.

ContextEither mMRC ≥2 OR CAT ≥10 required along with stable ICS+LABA+LAMA therapy for COPD initial authorization.

inv-101: Eosinophils on esophageal biopsy — >= 15 eos/hpf or 60 eos/mm2

Threshold>= 15 eos/hpf or 60 eos/mm2

ContextUpper endoscopy with biopsy showing this density of eosinophils required to confirm eosinophilic esophagitis (EoE).

Other requirementsDocumentation of symptoms (e.g., dysphagia) and failed 8-week PPI trial required; age ≥11 years.

Prior Authorization, Documentation, Step Therapy, and Denial Triggers

Denial Risk

Authorization requirement

Drugs on the Independent Health Medicare Advantage Part D formulary marked 'PA' require prior authorization.
Contact Medicare Member Services at 1-800-665-1502 (TTY 711) with questions.

Prior Authorization

Biologic group prior authorization and TB screening

Baseline TB screening (PPD or IGRA) required for biologic group except Otezla and Velsipity.
Initial authorization usually requires trial/failure or intolerance to ≥2 preferred agents (e.g., adalimumab biosimilar, Cosentyx, Enbrel, Rinvoq, Skyrizi, ustekinumab biosimilar, Xeljanz) where applicable.
If TB test is positive, coverage may be delayed until latent TB is treated; annual re‑screening or chest X‑ray may be required for ongoing therapy if exposure risk exists.

Prior Authorization

Caplacizumab prior authorization and recurrence limit

Caplacizumab prior authorization requires documentation of diagnosis and treatment context; use limits apply for recurrences.

Submit diagnosis of covered use and confirmation drug will be given with plasma exchange and immunosuppressive therapy.
If request is not for first use, submit previous aTTP recurrences while on caplacizumab.
Coverage will not be authorized if the patient has had more than 2 recurrences of aTTP while on therapy.
Coverage Duration: 3 months.

Prior Authorization

CFTR modulators prior authorization and required mutation testing

CFTR modulator (ivacaftor, lumacaftor/ivacaftor, tezacaftor/ivacaftor, elexacaftor/tezacaftor/ivacaftor) prior authorization requires confirmatory CFTR mutation testing per prescribing information.

Submit cystic fibrosis mutation test confirming presence of CFTR gene mutations appropriate for the requested drug: e.g., ivacaftor‑responsive mutation per PI for Kalydeco; F508del homozygous for Orkambi; responsive mutations per PI or in vitro data for Symdeko/Trikafta.
Prescriber restriction: pulmonology.
Coverage Duration: 1 year.

Documentation Required

PA requires diagnosis, prior therapy, and attestation

Prior authorization requests must include diagnosis, prior therapy history, and prescriber attestation of concomitant or continued standard therapies when required.

Document the diagnosis of covered use and submit current or prior therapies used to treat the condition where required.
Provider attestation that background or concomitant standard-of-care therapies will be continued after initiation of the requested agent (e.g., ICS‑LABA‑LAMA for COPD, triple inhaler regimen for asthma) when applicable.
Missing prior therapy or lab documentation is a common denial trigger.

Prior Authorization

Authorization and prior therapy requirements for oncology/specialty agents

Certain oncology and specialty agents require prerequisite therapy or prior targeted agents before approval; documentation of mutation testing or prior lines of therapy is frequently required.

Examples: ICLUSIG requests require documentation of T315I mutation status or resistance/intolerance to ≥2 prior kinase inhibitors for CP‑CML (non‑T315I).
GAVRETO and similar agents require tumor ROS1 or NTRK testing as applicable.
Many agents require documented failure/intolerance to specific prior therapies (e.g., crizotinib or entrectinib before GAVRETO; prior VEGFR inhibitor for FILSPARI).
Prescriber specialty restrictions often apply (oncology, hematology).

Prior Authorization

IMBRUVICA — prior authorization and hepatic/interaction exclusions

IMBRUVICA prior authorization requires hepatic assessment and prior therapy documentation for some indications; several cardiac and drug interaction exclusions apply.

Submit diagnosis and liver function testing or Child‑Pugh score; pregnancy status for females of childbearing potential.
For chronic graft‑versus‑host disease, document treatment failure with another systemic immunosuppressive agent.
Exclusions: severe hepatic impairment (Child‑Pugh class C) and coadministration with strong CYP3A inducers.
Prescriber restriction: hematology, oncology, transplant specialties.

Prior Authorization

ICLUSIG — prior authorization and interaction/exclusion triggers

Submit diagnosis and documentation of T315I mutation status (present or absent).
Provide baseline blood pressure reading and pregnancy status for females of childbearing potential.
Exclusions: newly diagnosed CP‑CML, uncontrolled hypertension.
For non‑T315I CP‑CML, document resistance or intolerance to at least two prior kinase inhibitors.
Prescriber restriction: hematology and oncology.

Prior Authorization

LENVIMA — prior authorization and required documentation

LENVIMA prior authorization requires documentation of diagnosis, baseline vitals/labs, pregnancy status, and indication‑specific prior therapies or coadministration attestations.

Submit diagnosis, baseline blood pressure, and pregnancy status for females of childbearing potential.
For thyroid cancer: attest radioactive iodine‑refractory or ineligible.
For renal cell carcinoma: attest coadministration with pembrolizumab or everolimus; if with everolimus, submit prior anti‑angiogenic therapy tried and failed.
Exclusions include uncorrected electrolyte abnormalities and uncontrolled hypertension.
Prescriber restriction: oncology. Coverage Duration: 1 year.

Documentation Required

Part B vs Part D coverage determination

If medication will be self‑administered after training or the provider agrees to have it filled at a pharmacy and delivered to the office by the patient for provider administration, it may be covered under Part D; otherwise it may be covered under Part B.
Include a description of how the drug will be used/obtained to determine Part B vs Part D coverage.

Prior Authorization

PA and reauthorization requirements

Reauthorization criteria commonly require evidence of clinical benefit or maintenance of previously achieved benefit and ongoing documentation of required background therapies and monitoring.

Reauthorization frequently requires documentation of symptomatic or clinical improvement (or maintenance of prior improvement), objective measures (e.g., labs, FEV1, exacerbation rates), or ongoing use of required background therapy.
Examples: dupilumab reauthorization requires continued use of background therapies and demonstration of benefit for asthma/COPD; QINLOCK reauthorization requires clinically relevant response in 24‑hour UFC for Cushing's syndrome.

Prior Authorization

Prior authorization and coverage duration

Prior authorizations typically specify a coverage duration (commonly 1 year) though some products have different limits (e.g., 12 weeks, 3 months, 30 days).

Common coverage duration for specialty drugs: 1 year.
Exceptions: HCV regimens often 12 weeks; caplacizumab coverage duration 3 months; tolvaptan for hyponatremia limited to 30 days to limit liver injury.
Document duration on the PA request and monitor reauthorization timing.

Prior Authorization

Tolvaptan (hyponatremia) PA rules

Tolvaptan for clinically significant hyponatremia requires initiation in a monitored setting, short‑term use only, and specific laboratory documentation to support the indication.

Submit evidence of clinically significant hyponatremia: serum sodium <125 mEq/L or symptomatic serum sodium <135 mEq/L resistant to fluid restriction.
Treatment must be initiated in a setting where serum sodium can be closely monitored.
Coverage is limited to 30 days to prevent liver injury; this formulation is not approved for ADPKD under this policy.

Documentation Required

General prior authorization requirements

Common baseline labs: liver function tests/Child‑Pugh, serum transaminases, bilirubin, ALP, CBC with differential, serum potassium and magnesium, ECG/QTc (or QTcF) when QT‑prolonging risk exists.
Provide pregnancy status for females of childbearing potential.
Attach documentation of prior therapies and line/step therapy trials when required; missing labs or prior therapy documentation can trigger denial.

Prior Authorization

Verquvo prior authorization requirements

Verquvo (vericiguat) prior authorization requires documentation of recent HF hospitalization or IV diuretic use, reduced LVEF, and prior therapies for HFrEF.

Submit diagnosis including either hospitalization for HFrEF within previous 6 months or outpatient IV diuretic use within previous 3 months.
Provide left ventricular ejection fraction (<45%) and pregnancy status for females of childbearing potential.
Submit current or previous therapies used to treat HFrEF; prescriber restriction: cardiology.

Denial Risk

Exclusion criteria and denial triggers (drug interactions, hepatic, cardiac, electrolyte, pregnancy, cosmetic)

Drug interaction exclusions: examples include prohibition of moderate/strong CYP3A inhibitors/inducers with ICLUSIG, GAVRETO, VANFLYTA, and others; proton pump inhibitors/H2 antagonists exclude some agents (e.g., certain TKIs).
Hepatic exclusions: severe hepatic impairment (Child‑Pugh C) excludes many agents (IMBRUVICA, Trikafta severe hepatic impairment, others).
Cardiac/QT exclusions: baseline QTc >450–470 msec depending on product, congenital long QT, history of torsades de pointes; require baseline ECG/QTcF and electrolytes (K+, Mg2+).
Electrolyte and hematologic exclusions: uncorrected hypokalemia/hypomagnesemia, neutropenia thresholds, platelet/ANC minima for some therapies.
Pregnancy and reproductive status: many agents require pregnancy status; teratogenic agents require negative pregnancy testing and counseling.
Age and indication‑specific exclusions may apply; cosmetic uses (e.g., topical retinoids for cosmetic indications) are excluded.

Documentation Required

Required diagnostic and laboratory documentation; missing tests cause denials

PAH: submit right heart catheterization results, WHO Group classification, mean pulmonary arterial pressure >20 mm Hg, PAWP ≤15 mm Hg, PVR thresholds, creatinine clearance, and pregnancy status.
MAC lung disease (e.g., ARIKAYCE): document multi‑drug MAC regimen tried and failed for ≥6 months and positive sputum culture obtained after treatment.
Cardiac/QT‑risk drugs: submit ECG/QTcF, serum potassium, and serum magnesium.
Oncology/targeted therapies: submit tumor mutation testing (ALK, ROS1, NTRK, BRCA, IDH2, FGFR, RET, etc.) and prior lines/agents used.
Dupilumab: submit diagnosis and current background therapy and provider attestation that background therapy will continue where required.

Step Therapy

Prior therapy, step therapy, and course limits

Examples: AUVELITY requires failure of standard therapies prior to approval; Opsumit initial authorization requires prior failure/intolerance to ambrisentan or bosentan.
PCSK9 inhibitors (Repatha) typically require ≥8 weeks of high‑intensity statin therapy with inadequate LDL response, or documented statin intolerance or rhabdomyolysis.
Oncology agents frequently require prior chemotherapy lines or specific prior targeted therapy as detailed per drug entry.
Document trial durations (e.g., MAC regimen ≥6 months) and reasons for discontinuation (intolerance, lack of efficacy).

Initial Authorization / Step Therapy Requirements

Requirement	Example documentation
Documentation that patient has used prior statin therapy (or current statin use unless contraindicated)	Medication history showing statin name, dose, duration; evidence of intolerance or inadequate LDL response
If applicable, documentation of prior statin trials including at least one hydrophilic statin previously tried and failed	Clinical notes or lab results showing LDL levels before and after statin therapy or notes explaining intolerance (e.g., rhabdomyolysis)

Required before initial authorization of CAMZYOS	Documentation/examples
Trial and inadequate response or intolerance to both a beta-blocker and a non‑DHP calcium channel blocker	Provider attestation that both classes were tried and patient had inadequate response or intolerance
Clinical medication list showing agents, doses, and treatment dates for beta‑blocker and non‑DHP CCB trials	Cardiology evaluation documenting persistent NYHA II–III symptoms despite trials; echocardiogram or hemodynamic data confirming LVOT gradient and LV wall thickness per criteria

Emgality prevention step	Example documentation
Trial and inadequate response or intolerance to Aimovig (erenumab) prior to Emgality for migraine prevention	Statement that Aimovig was tried and failed or was contraindicated
Medication history showing Aimovig prescription dates and reason for discontinuation (lack of efficacy or adverse events)	Baseline headache days per month from chart and documentation of lack of improvement on Aimovig

Reauthorization and Monitoring Requirements

Step and Failure Requirements

Step therapy — prior trials required	Documentation/examples
For ITP: documentation of failure of at least two ITP therapies from different classes prior to DOPTELET (e.g., systemic corticosteroids, IVIG, danazol, fostamatinib, cytotoxics/immunosuppressants)	Submission of current platelet counts meeting threshold criteria per indication
Medication records showing prior ITP therapies tried, dates, doses, and reasons for discontinuation or lack of efficacy	Laboratory results showing platelet counts before and after prior therapies and at time of request

Step therapy — CAMZYOS prerequisite	Documentation/examples
Trial and inadequate response or intolerance to both a beta‑blocker and a non‑DHP calcium channel blocker prior to mavacamten initiation	Provider attestation that both classes were used and were ineffective or not tolerated
Medication history listing specific beta‑blocker and non‑DHP CCB agents, doses, treatment duration, and reason for discontinuation	Cardiology assessment documenting symptomatic NYHA II–III status and supporting echocardiographic measurements (LVOT gradient, LV wall thickness) per CAMZYOS criteria

Emgality step requirement — migraine prevention	Required documentation
Documentation Aimovig (erenumab) was tried and had inadequate response before Emgality for prevention	If Aimovig contraindicated, clinical rationale for contraindication must be provided
Medication history showing Aimovig treatment dates and clinical response; headache diary or charted headache days per month pre‑ and on‑therapy	For first reauthorization: on‑treatment headache days demonstrating improvement from baseline

DOPTELET step requirement — ITP prior trials	Required documentation examples
Failure of at least two ITP therapies from different classes before initial DOPTELET authorization	Platelet count meeting ITP threshold (<30 x10^9/L or <50 x10^9/L with symptomatic bleeding) documented
Records of prior ITP therapies with dates, doses, and reasons for failure/intolerance (e.g., corticosteroids, IVIG, rituximab)	Platelet count lab reports before and after prior therapies and at request time; splenectomy status if applicable

Oncology & specialty agents — prior trials/failures	Documentation/examples
Documentation of trials and failures or intolerances to specified prior agents or classes as listed in each product section (e.g., prior VEGFR inhibitors, prior chemotherapy regimens, prior ALK/ROS1 inhibitors)	Attestation that listed prior therapies were tried and failed or were contraindicated/intolerable
Oncology med history with regimen names, dates, responses, and reason for discontinuation; pathology/genetic testing confirming target (e.g., ROS1, ALK)	Relevant labs and safety data (e.g., baseline BP, LFTs, Child‑Pugh score) when required per product

Generic step examples — documentation to include	Examples of acceptable evidence
Document prior therapies tried and the specific reason for failure or intolerance where required by policy	Include medication names, doses, start/stop dates, and clinical rationale for switching or stopping therapy
Laboratory data, imaging, or specialist notes supporting lack of efficacy or intolerance (e.g., LDL levels, liver tests, blood counts, ECGs)	For biologics: documentation of trials of preferred on‑formulary alternatives and TB screening or other baseline tests where required

Course Limits and Quantity Restrictions

inv-286: Vowst — 1 course

Quantity limit1 course

DrugVowst

ContextAuthorized quantity limit for Vowst per policy.

inv-287: Xifaxan (rifaximin) for IBS-D — 3

Quantity limit3 (max lifetime 14-day courses)

DrugXifaxan (rifaximin) — IBS-D

ContextDocumentation of number of prior 14-day courses required for authorization.

inv-288: Xifaxan (rifaximin) for SIBO — 2

Quantity limit2 (max 14-day courses per 365 days)

DrugXifaxan (rifaximin) — SIBO

ContextPositive carbohydrate breath test and prior course documentation required for SIBO authorization.

Administration Site, Part B vs Part D, and Initiation Requirements

Note

Policy Background and Scope

inv-239: Coverage Duration — The authorized time period for coverage (commonly 1 year for many listed products; exceptions noted where shorter durations apply).

DefinitionThe authorized time period for coverage (commonly 1 year for many listed products; exceptions noted where shorter durations apply).

Typical duration1 year is the common coverage duration for most specialty drugs in this policy.

ExceptionsSome products have shorter authorized durations (e.g., tolvaptan for hyponatremia limited to 30 days; Vowst limited to 1 course; EoE max 12-week course per 365 days).

Clinical Definitions and Thresholds

inv-222: Baseline latent TB screening — A Mantoux tuberculin skin test (PPD) or interferon-gamma release assay (IGRA) required prior to initiating many biologic/immunomodulatory...

RequirementMantoux PPD or interferon-gamma release assay (IGRA) prior to initiating most biologic/immunomodulatory therapies (except Otezla and Velsipity)

Action on positive resultIf TB screening is positive, coverage is delayed until latent TB is treated.

ReauthorizationYearly TB screening or chest X-ray required for patients with ongoing high TB exposure risk while on treatment.

Mean pulmonary arterial pressure>20 mm Hg at rest

PAWP≤15 mm Hg

PVR>2 Wood units (WHO Group 1) or >3 Wood units for CTEPH)

inv-228: EoE histology threshold — Biopsy showing at least 15 eosinophils per high-power field (or 60 eos/mm2) required for eosinophilic esophagitis.

Threshold>= 15 eos/hpf or 60 eos/mm2

ContextHistologic criterion required on esophageal biopsy to diagnose eosinophilic esophagitis (EoE).

Other requirementsSymptoms consistent with EoE and failed 8-week PPI trial required for authorization.

Document Updates

2026-01-14policy_effectiveLatest

Policy effective date updated to 2026-01-14 for the Independent Health Medicare Advantage Part D prior authorization index and criteria.

Policy Summary

PayerIndependent Health

PolicyPrior Authorization Criteria for Medicare Part D Formulary Drugs

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateJan 14, 2026

Next Review DateN/A

SourceLink

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