Step therapy criteria for Child Health Plus formulary medications
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Defines step therapy rules that require trying specified medications or demonstrating prior medication history before covering certain formulary drugs for Independent Health Child Health Plus members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Step Therapy and Formulary Rules
Entacapone coverage criteria
Entacapone
If not met, prior authorization required
Desonide coverage criteria
Desonide 0.05% external
If not met, prior authorization required
Aprepitant coverage criteria
Aprepitant
If not met, prior authorization required
Eucrisa coverage criteria
Eucrisa
If not met, prior authorization required
Granisetron coverage criteria
Granisetron
If not met, prior authorization required
Opioid/fentanyl coverage criteria
Opioid ER and fentanyl patches
If not met, prior authorization required
Aliskiren coverage criteria
Aliskiren
If not met, prior authorization required
Serevent coverage criteria
Serevent Diskus
If not met, prior authorization required
Ubrelvy coverage criteria
Ubrelvy
If not met, prior authorization required
Ubrelvy
Ubrelvy routing criteria
Uloric (febuxostat)
Uloric (febuxostat) routing criteria
This step therapy list applies specifically to Independent Health's Child Health Plus formulary and is current as of 6/1/2026. The formulary and associated protocols may change; members will receive notice of changes. For questions, providers or pharmacists may contact Member Services at the phone numbers shown in the formulary excerpt.
The provided excerpt contains an index of covered product presentations (e.g., multiple pen/auto‑injector and tablet strengths) but does not list explicit exclusions. No medications or indications are identified in this partial extract as being specifically excluded from coverage.
Coding, Lookback Windows, and Drug Presentation Index
| 15 MG/0.5ML | MOUNJARO SOLUTION AUTO-INJECTOR 15 MG/0.5ML (listed repeatedly as index entry) |
| 0.25 OR 0.5 MG/DOSE | OZEMPIC SOLUTION PEN-INJECTOR (0.25 or 0.5 mg/dose) SUBCUTANEOUS |
| 1 MG/DOSE | OZEMPIC SOLUTION PEN-INJECTOR (1 mg/dose) SUBCUTANEOUS |
| 2 MG/DOSE | OZEMPIC SOLUTION PEN-INJECTOR (2 mg/dose) SUBCUTANEOUS |
| 14 MG | RYBELSUS TABLET 14 MG ORAL |
| 3 MG | RYBELSUS TABLET 3 MG ORAL |
| 7 MG | RYBELSUS TABLET 7 MG ORAL |
| 50 MCG/ACT | SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT INHALATION |
| 0.75 MG/0.5ML | TRULICITY SOLUTION AUTO-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS |
| 1.5 MG/0.5ML | TRULICITY SOLUTION AUTO-INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS |
Provider Actions, Prior Authorization Triggers, and Documentation
GLP-1 Prior Authorization
Prior Authorization Required: A prescription for an antidiabetic GLP-1 medication is processed automatically if the patient's Independent Health prescription history documents type 2 diabetes or records that the patient has tried any oral antidiabetic drug (excluding metformin) within the past 130 days. If the pharmacy profile does not meet this criterion, prior authorization is required.
- Products affected include multiple GLP-1 agents (e.g., Mounjaro, Ozempic, Rybelsus, Trulicity) as listed in the index/product presentations.
- Pharmacy must reference the member's Independent Health prescription history to determine if the trigger criteria are met.
- If history does not document the required diagnosis or prior oral antidiabetic use (excluding metformin) within 130 days, submit a prior authorization request.
GLP-1 Step Therapy Rule
Step Therapy Rule: Certain GLP-1 products are subject to step therapy protocols as part of Independent Health's formulary. The prescriber and pharmacy should confirm whether an ST designation applies in the member's formulary and follow required trial steps before coverage of a nonpreferred GLP-1 agent is authorized.
- Confirm step-therapy status on the member formulary (ST note) prior to prescribing or dispensing.
- If step requirements are not met, prior authorization or supporting documentation may be required.
Opioid ER/Fentanyl Prior Authorization
Opioid ER/Fentanyl Prior Authorization: A prescription for listed extended-release opioid or fentanyl products will process online only if the patient's Independent Health prescription history documents that narcotic medications were filled within the previous 120 days. If the pharmacy profile does not show such fills within 120 days, prior authorization is required.
- Affected products include multiple extended-release opioid formulations (examples listed in source).
- Pharmacy must check Independent Health prescription history for narcotic fills within prior 120 days before processing.
- If required history is absent, the prescriber must submit a prior authorization with clinical justification.
Pharmacy Must Reference Independent Health Prescription History
Pharmacy Operational Requirement: Pharmacies must reference the member's Independent Health prescription history when determining whether a prescription meets automatic processing triggers (e.g., prior fills, concurrent therapies). When the profile does not meet the documented criteria, prior authorization is required.
- Always verify Independent Health prescription history for trigger conditions (diagnosis or prior medication fills) before dispensing.
- If the pharmacy profile lacks the required history, advise prescriber to submit PA documentation.
Product Index and Presentation Examples
Product Index / Presentation Examples: The document includes an index of affected products and examples of product presentations (strengths and packaging) for pharmacy and provider reference. This section is informational and does not itself list prior authorization details beyond indicating which products are subject to the rules above.
- Index entries list product presentations (e.g., strengths, formulations, pen/auto-injector volumes, tablet strengths).
- Use the index to identify specific NDC/product presentations when submitting prior authorization or checking step-therapy applicability.
- The index itself does not change prior authorization criteria — it maps products to the applicable rules described above.
GLP-1 Antidiabetic Prior Authorization Trigger
GLP-1 Antidiabetic Prior Authorization Trigger: Operational trigger — a GLP-1 antidiabetic prescription is allowed to process online when the member's Independent Health prescription history documents either a diagnosis of type 2 diabetes or prior fills of an oral antidiabetic (excluding metformin) within 130 days. Absent this documentation, the pharmacy must obtain prior authorization.
- Trigger lookback window: 130 days for prior oral antidiabetic fills (excluding metformin).
- Trigger conditions: documented type 2 diabetes diagnosis OR documented prior oral antidiabetic use (excluding metformin).
- If neither condition is present in the Independent Health prescription history, submit prior authorization.
No Other Explicit Provider Actions
No Additional Provider Actions Stated: Within these source chunks there are no other explicit provider actions beyond verifying prescription history, following step-therapy protocols, and submitting prior authorization when criteria are not met.
- If further documentation or clinical information is required, the PA process will request it; no other discrete actions are specified in these excerpts.
Initial Therapy — Online Pass / Prior Authorization Conditions
GLP-1 initial therapy
GLP-1 agents pass online with documented prior oral antidiabetic or diagnosis
Applies to listed GLP-1 products
Ubrelvy initial therapy requirement
Examples listed: sumatriptan, naratriptan, rizatriptan.
Uloric initial therapy requirement
Step Therapy Steps, Lookback Windows, and Required Prior Fills
| Requirement | Lookback / window | Provider action to avoid prior authorization |
|---|---|---|
| Documented type 2 diabetes or prior oral antidiabetic (excluding metformin) | ||
| 130 days | ||
| Ensure Independent Health prescription history shows diagnosis of type 2 diabetes or a filled oral antidiabetic (not metformin) within past 130 days |
| Coverage requirement | Lookback / window | Provider action to avoid prior authorization |
|---|---|---|
| Evidence of prior generic triptan fill (e.g., sumatriptan, naratriptan, rizatriptan) | ||
| 120 days | ||
| Confirm Independent Health prescription history documents a generic triptan filled within the previous 120 days before submitting Ubrelvy |
| Coverage requirement | Lookback / window | Provider action to avoid prior authorization |
|---|---|---|
| Evidence of prior allopurinol fill | ||
| 90 days | ||
| Ensure Independent Health prescription history shows an allopurinol fill within the previous 90 days before submitting febuxostat (Uloric) |
| Presentation | Form / strength as listed in index | Notes |
|---|---|---|
| MOUNJARO | ||
| 15 MG/0.5ML solution auto-injector (also other strengths listed) | ||
| Indexed as multiple auto-injector presentations in policy index | ||
| OZEMPIC | ||
| 0.25 or 0.5 mg/dose; 1 mg/dose; 2 mg/dose solution pen-injector | ||
| Multiple pen strengths listed in index | ||
| RYBELSUS | ||
| Tablets: 3 mg, 7 mg, 14 mg | ||
| Listed as oral tablet presentations in index | ||
| TRULICITY | ||
| Auto-injector: 0.75, 1.5, 3, 4.5 mg/0.5 mL | ||
| Multiple auto-injector strengths listed | ||
| SEREVENT DISKUS | ||
| Aerosol powder breath activated 50 MCG/ACT inhalation | ||
| Listed in index; routing criteria elsewhere in policy | ||
| UBRELVY | ||
| Tablets: 50 mg, 100 mg | ||
| Indexed presentations for ubrogepant |
Background and Rationale
Step therapy is a utilization-management approach that requires a patient to try specified first-line or established therapies before a different medication will be covered. In this formulary, step therapy protocols are used to promote clinically appropriate, cost-effective prescribing (for example, trying an established generic before a brand-name agent) and to ensure required concurrent therapies are used when indicated. Medications subject to step therapy are noted with an 'ST' on the formulary, and pharmacy history or documented prior fills are used to determine whether a prescription will route online or require prior authorization.
Definitions and Terms
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