Step therapy protocols for select drugs
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Defines step therapy requirements for specific drugs on Independent Health Medicare Advantage Part D formularies; applies to prescribers and pharmacy prior authorization reviewers for affected Medicare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Product-specific Step Therapy
Aliskiren
Covered when the following prior therapy has been tried
applies to aliskiren fumarate tablet 300 mg oral
Aripiprazole formulations
Formulation-sequencing requirements
applies to aripiprazole orally-disintegrating tablet (ODT)
applies to aripiprazole oral film products (e.g., OPIPZA FILM)
EUCRISA
Topical therapy sequencing
applies to EUCRISA ointment
Febuxostat
Gout urate-lowering therapy sequencing
applies to febuxostat tablets (e.g., 40 mg, 80 mg)
SYMPAZAN
Clobazam sequencing for clobazam-containing product
applies to SYMPAZAN film products
Trelstar MixJect
GnRH analog sequencing
applies to TRELSTAR MixJect suspension formulations (reconstituted)
Versacloz / Doxercalciferol
Clozapine and vitamin D analog sequencing
applies to VERSACLOZ suspension 50 mg/mL oral
applies to doxercalciferol capsule 2.5 mcg oral
The formulary listed in this document applies to Independent Health Medicare Advantage Part D formularies and is current as of 3/1/2026. The formulary may change at any time; members will receive notice when changes are necessary.
Actions Required from Prescribers and Reviewers
Step therapy requirement
Step therapy protocols apply for drugs on the Medicare Advantage Part D formularies listed; prescribers must document prior use of required agents per the listed criteria to obtain coverage.
- Documentation must show trial and inadequate response, intolerance, or contraindication to the required prior agent to advance to the requested product.
Product-specific step requirements
Specific products in this list require documented prior trials of the agent(s) named in each product’s coverage criteria; see the coverage module for each product for the exact prior-agent requirement.
- Must trial the specified prior agent(s) listed for each product before coverage of the requested product is approved.
Medicare Member Services contact
For questions about coverage or step therapy requirements, contact Medicare Member Services at 1-800-665-1502 (TTY 711). Member service hours: Oct 1–Mar 31: Monday–Sunday 8 a.m.–8 p.m.; Apr 1–Sep 30: Monday–Friday 8 a.m.–8 p.m.
Aliskiren 300 mg: prior ARB trial required
Coverage for aliskiren fumarate 300 mg oral requires prior use of an angiotensin‑II receptor blocker (ARB); prescribers must document a prior ARB trial.
Aripiprazole formulation sequencing
Aripiprazole formulation sequencing must be followed: orally‑disintegrating tablets (ODT) require prior use of aripiprazole oral solution; aripiprazole oral films require prior use of aripiprazole ODT. Document the appropriate prior formulation trial.
EUCRISA: prior topical therapy required
EUCRISA (ointment 2%) requires prior use of either a topical corticosteroid or a topical calcineurin inhibitor; prescribers must document trial of one of these topical therapies.
Febuxostat: prior allopurinol trial required
Febuxostat (including 40 mg and 80 mg listings) requires prior use of allopurinol; document a prior allopurinol trial before requesting febuxostat.
SYMPAZAN: prior clobazam suspension required
SYMPAZAN film products require prior use of clobazam oral suspension; documentation of a prior clobazam suspension trial is required for coverage.
Trelstar MixJect: prior Lupron Depot required
TRELSTAR MixJect formulations listed require prior use of Lupron Depot; document a prior Lupron Depot trial for authorization.
Clozapine/doxercalciferol sequencing
VERSACLOZ suspension requires prior use of clozapine orally‑disintegrating tablet (ODT); separately, doxercalciferol 2.5 mcg requires prior use of calcitriol. Providers must document the applicable prior-agent trial.
Initial Therapy Requirements
Initial therapy requirements
Initial coverage requires documented trial and failure or contraindication to the required prior agent(s) listed per product.
see product-specific criteria
see product-specific criteria
see product-specific criteria
see product-specific criteria
see product-specific criteria
see product-specific criteria
see product-specific criteria
see product-specific criteria
Step Therapy Table — Required Prior Agents
| Product | Required prior agent(s) / sequence | Notes |
|---|---|---|
| Aliskiren fumarate tablet 300 mg oral | ||
| Angiotensin-II receptor blocker (ARB) | ||
| Requires prior ARB trial before coverage | ||
| Aripiprazole tablet dispersible 10 mg; Aripiprazole tablet dispersible 15 mg; OPIPZA FILM (as applicable) | ||
| Aripiprazole oral solution → Aripiprazole ODT → Aripiprazole oral film (films require prior ODT; ODT requires prior oral solution) | ||
| Formulation-specific sequencing; ODT = orally-disintegrating tablet | ||
| EUCRISA ointment 2% | ||
| Topical corticosteroid OR topical calcineurin inhibitor | ||
| Either topical steroid or topical calcineurin inhibitor must be tried first | ||
| Febuxostat tablet 40 mg; Febuxostat tablet 80 mg | ||
| Allopurinol | ||
| Allopurinol must be tried prior to febuxostat | ||
| SYMPAZAN FILM (5 mg, 10 mg, 20 mg) | ||
| Clobazam oral suspension | ||
| Clobazam suspension required prior to Sympazan films | ||
| TRELSTAR MIXJECT suspension (reconstituted 3.75 mg, 11.25 mg, 22.5 mg) | ||
| Lupron Depot | ||
| Lupron Depot must be tried before Trelstar MixJect formulations | ||
| VERSACLOZ suspension 50 mg/mL oral | ||
| Clozapine orally-disintegrating tablet (ODT) | ||
| Clozapine ODT required prior to Versacloz suspension | ||
| Doxercalciferol capsule 2.5 mcg (also 0.5 mcg, 1 mcg listed) | ||
| Calcitriol | ||
| Calcitriol must be tried prior to doxercalciferol 2.5 mcg |
Definitions and Abbreviations
Background — Step Therapy Rationale
Step therapy is a utilization management technique that requires a trial of a preferred or lower-cost medication before coverage of an alternative agent will be approved. This document lists the step requirements associated with the Medicare Advantage Part D formularies and explains that prescribers must document prior trials of the required agents to obtain coverage; if the preferred agent is ineffective, intolerable, or contraindicated, the next-step product may be covered.
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