Step therapy criteria for Child Health Plus formulary medications
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Defines step therapy protocols that apply to Independent Health's 2025 Child Health Plus formulary; describes which medications require prior trial of specified agents or documentation in pharmacy history before coverage or prior authorization is applied. Affects providers prescribing and pharmacies filling medications for Child Health Plus members.
No material clinical or coverage changes in this revision.
Coverage Criteria — Product-specific Step Rules
Airsupra
Covered when ALL of the following are met:
If not documented, prior authorization is required.
GLP-1 antidiabetic agents
Covered when ONE of the following is documented in the Independent Health pharmacy history:
Applies to listed GLP-1 products (e.g., Mounjaro, Ozempic, Rybelsus, Trulicity). If not documented, prior authorization is required.
Entacapone
Covered when ALL of the following are met:
If not documented, prior authorization is required.
Desonide 0.05%
Covered when ALL of the following are met:
If not documented, prior authorization is required.
Aprepitant
Covered when ALL of the following are met:
If not documented, prior authorization is required.
Eucrisa
Covered when ANY of the following are met:
If not documented, prior authorization is required.
Granisetron
Covered when ALL of the following are met:
If not documented, prior authorization is required.
Long-acting and abuse-deterrent opioids
Covered when ALL of the following are met:
Applies to listed long-acting and abuse‑deterrent opioid products; if not documented, prior authorization is required.
Aliskiren
Covered when ALL of the following are met:
If not documented, prior authorization is required.
Serevent Diskus
Covered when ONE of the following is documented in the pharmacy history:
If not documented, prior authorization is required.
Serevent Diskus (alternate index)
Online routing occurs when ONE of the following is present in the pharmacy profile:
If not documented, prior authorization is required.
Tramadol ER
Initial coverage routing — covered when ALL of the following are met:
If not documented, prior authorization is required and claim will not route online.
Ubrelvy
Covered when ONE of the following is documented in the pharmacy history:
If not documented, prior authorization is required.
Febuxostat
Covered when ONE of the following is documented in the pharmacy history:
If not documented, prior authorization is required.
This excerpt contains the Step Therapy Criteria applicable to Independent Health's 2025 Child Health Plus formulary. No explicit clinical exclusions are listed in this part of the document; the rules shown rely on documented pharmacy history or diagnosis to route claims or trigger prior authorization rather than stating specific patient-level exclusions.
For the products shown in this excerpt, the policy sets coverage routing based on the member's pharmacy history (for example, documented concurrent controller therapy for inhalers). No explicit clinical exclusions for these products are provided within this section — coverage decisions are determined by the presence or absence of required prior fills rather than named clinical contraindications.
Within this portion of the policy there are no statements declaring items 'not medically necessary'. Instead, the document describes step therapy checks and prior authorization triggers tied to pharmacy history and predefined lookback windows; absence of required history prompts prior authorization rather than an explicit non‑coverage declaration.
Coding and Lookback Windows
| MOUNJARO SOLUTION AUTO-INJECTOR 10 MG/0.5ML SUBCUTANEOUS | listed product |
| OZEMPIC (2 MG/DOSE) SOLUTION PEN-INJECTOR 8 MG/3ML SUBCUTANEOUS | listed product |
| RYBELSUS TABLET 14 MG ORAL | listed product |
| TRULICITY SOLUTION AUTO-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS | listed product |
| FENTANYL PATCH 72 HOUR 100 MCG/HR TRANSDERMAL | listed product |
| HYDROCODONE BITARTRATE ER TABLET 24 HOUR 100 MG ORAL | listed product |
| MORPHINE SULFATE ER CAPSULE 24 HOUR 100 MG ORAL | listed product |
| NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 100 MG ORAL | listed product |
| entacapone tablet 200 mg oral | listed product |
| EUCRISA OINTMENT 2 % EXTERNAL | listed product |
| granisetron hcl tablet 1 mg oral | listed product |
| aliskiren fumarate tablet 150 mg oral | listed product |
| aliskiren fumarate tablet 300 mg oral | listed product |
| SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT INHALATION | listed product |
Provider Actions — Prior Authorization Triggers & Documentation
Prior authorization required when history criteria not met
Many medications require prior authorization when the member’s Independent Health pharmacy history does not document the product-specific prior therapy or diagnosis within the lookback window; absence of the required history will trigger a PA requirement and may result in denial without an approved authorization.
- Lookback windows vary by product (examples: 90, 120, 130, 180, 365 days).
- Specific products and their required prior therapy are described in product-level rules below.
Serevent prior authorization
If the pharmacy profile does not document concurrent use of an inhaled corticosteroid or Spiriva (tiotropium), prior authorization is required for Serevent Diskus.
- Claim routes online only when pharmacy history documents concurrent inhaled corticosteroid or Spiriva.
Tramadol ER prior authorization
Prior authorization is required for extended‑release tramadol when the pharmacy profile does not document a fill of immediate‑release tramadol within the previous 90 days.
- Online routing allowed only if an immediate‑release tramadol fill is documented within the 90‑day lookback.
Ubrelvy prior authorization
Prior authorization is required for Ubrelvy (ubrogepant) when the pharmacy profile does not document a generic triptan fill within the previous 120 days.
- Examples of acceptable generics include sumatriptan, naratriptan, rizatriptan as documented in pharmacy history.
Febuxostat prior authorization
Prior authorization is required for febuxostat (Uloric) when the pharmacy profile does not document an allopurinol fill within the previous 90 days.
- Online routing permitted only if allopurinol fill is present in the 90‑day lookback window.
Formulary step therapy designation — ST designation note
Medications listed with an 'ST' designation on the Child Health Plus formulary are subject to the step therapy protocols in this document; the initial step is verification of the product‑specific prior therapy or diagnosis in the member's pharmacy history.
- If the required prior therapy is not documented, prior authorization is required per the product rule.
Serevent step rule
Serevent Diskus requires documented concurrent use of an inhaled corticosteroid or tiotropium (Spiriva) on the pharmacy profile to satisfy the step and allow online processing; absence requires prior authorization.
- Concurrent controller documentation is the step required for online routing.
Tramadol ER step rule
Extended‑release tramadol products require a documented immediate‑release tramadol fill within the previous 90 days as the step to allow online processing; otherwise prior authorization is required.
- 90‑day lookback for immediate‑release tramadol is enforced.
Ubrelvy step rule
Ubrelvy (ubrogepant) requires documentation of a generic triptan fill within the previous 120 days as the step to permit online routing; if not documented, prior authorization is required.
- Acceptable evidence is a pharmacy fill for a generic triptan within 120 days.
Febuxostat step rule
Febuxostat (Uloric) requires documentation that allopurinol was filled within the previous 90 days as the step to allow online processing; absence of that fill triggers prior authorization.
- 90‑day allopurinol lookback applies to both 40 mg and 80 mg febuxostat products.
Required pharmacy history documentation — general
Pharmacy profile/prescription history must document the product‑specific prior fills or diagnoses within the defined lookback windows (examples: 90, 120, 130, 180, 365 days) to satisfy step requirements; absence will require prior authorization.
- Lookback window examples: GLP‑1 agents 130 days; Ubrelvy 120 days; tramadol ER and febuxostat 90 days; granisetron 180 days; Eucrisa 365 days.
Serevent documentation — concurrent inhaled corticosteroid or tiotropium
For Serevent Diskus, document concurrent use of an inhaled corticosteroid or tiotropium (Spiriva) in the pharmacy/prescription history to meet the requirement and allow online processing.
- If not documented, a prior authorization will be required.
Tramadol ER documentation — immediate‑release tramadol within 90 days
For extended‑release tramadol prescriptions, include prescription history showing an immediate‑release tramadol fill within the previous 90 days to meet the step requirement and avoid prior authorization.
- 90‑day lookback must show immediate‑release tramadol fill.
Ubrelvy documentation — generic triptan within 120 days
For Ubrelvy, provide prescription history documenting a generic triptan fill (e.g., sumatriptan, naratriptan, rizatriptan) within the previous 120 days to meet the step requirement and allow online processing.
- 120‑day lookback for a generic triptan is required.
Febuxostat documentation — allopurinol within 90 days
For febuxostat, ensure the pharmacy history documents an allopurinol fill within the previous 90 days (for either 40 mg or 80 mg strengths) to meet the step requirement and avoid prior authorization.
- 90‑day allopurinol fill must be present in pharmacy history.
Airsupra: inhaled corticosteroid history required
Airsupra prescriptions require pharmacy history documentation that an inhaled corticosteroid or its combination was filled within the previous 120 days; absence of that documentation will require prior authorization.
- 120‑day lookback for inhaled corticosteroid or combination (examples: budesonide suspension, fluticasone‑salmeterol).
GLP-1 agents: prior oral antidiabetic or diagnosis required
For GLP‑1 antidiabetic agents, pharmacy history must document type 2 diabetes OR a trial of any oral antidiabetic (excluding metformin) within the previous 130 days; if neither is documented, prior authorization is required.
- 130‑day lookback applies to GLP‑1 products listed on the formulary.
Entacapone: concurrent carbidopa/levodopa required
Entacapone requires pharmacy history documenting concurrent use of carbidopa/levodopa; absence of concurrent carbidopa/levodopa will require prior authorization.
- Concurrent carbidopa/levodopa must appear in the member’s prescription history.
Desonide: prior topical steroid required
Desonide 0.05% requires prior pharmacy documentation that alclometasone was filled within the previous 90 days; without that prior topical steroid fill, prior authorization will be required.
- 90‑day lookback for alclometasone is enforced.
Aprepitant: dexamethasone history required
Aprepitant products require pharmacy history documentation of at least a five‑day supply of dexamethasone filled within the previous 90 days; absence will require prior authorization.
- Document a five‑day dexamethasone supply within 90 days in the prescription history.
Eucrisa: prior topical therapy required
Eucrisa ointment requires documented prior use of a topical corticosteroid or a topical calcineurin inhibitor (e.g., pimecrolimus or tacrolimus) within the previous 365 days; if not documented, prior authorization is required.
- 365‑day lookback for prior topical corticosteroid or calcineurin inhibitor.
Granisetron: ondansetron history required
Granisetron requires pharmacy history documenting that ondansetron was filled within the previous 180 days; absence of that documentation will require prior authorization.
- 180‑day lookback for ondansetron is enforced.
Opioids: recent narcotic use required
A range of long‑acting and abuse‑deterrent opioid products require documentation that narcotic medications were filled within the previous 120 days; lack of a recent narcotic fill will require prior authorization.
- 120‑day lookback for prior narcotic medication fills applies to multiple listed opioid products.
Aliskiren: ACE inhibitor and ARB history required
Aliskiren tablets require pharmacy history documenting fills for an ACE inhibitor and an ARB within the previous 90 days; absence of both will require prior authorization.
- 90‑day lookback for both ACE inhibitor and ARB fills is required.
Serevent Diskus: concurrent controller required
Serevent Diskus requires documentation of concurrent use of an inhaled corticosteroid or tiotropium (Spiriva) in the pharmacy history; if the profile does not document this concurrent controller therapy, the claim may be denied without prior authorization.
- Concurrent inhaled corticosteroid or Spiriva must be present in the pharmacy profile to avoid denial.
Serevent denial trigger
If the pharmacy profile does not document concurrent inhaled corticosteroid or Spiriva use for Serevent Diskus, prior authorization is required and the claim may be denied without it.
- Lack of documented controller therapy is a denial trigger for Serevent Diskus.
Tramadol ER denial trigger
If the pharmacy profile does not document an immediate‑release tramadol fill within the previous 90 days for extended‑release tramadol products, prior authorization is required and the claim may be denied without it.
- Absence of the 90‑day immediate‑release tramadol fill is a denial trigger for tramadol ER.
Ubrelvy denial trigger
If the pharmacy profile does not document a generic triptan fill within the previous 120 days for Ubrelvy, prior authorization is required and the claim may be denied without it.
- Absence of a 120‑day triptan fill is a denial trigger for Ubrelvy.
Febuxostat denial trigger
If the pharmacy profile does not document an allopurinol fill within the previous 90 days for febuxostat (Uloric), prior authorization is required and the claim may be denied without it.
- Absence of a 90‑day allopurinol fill is a denial trigger for febuxostat.
Background and Policy Purpose
Step therapy is used to ensure that members try clinically appropriate, typically less expensive or preferred therapies before receiving other formulary medications. The protocol in this document enforces step requirements by checking the member's Independent Health pharmacy history for prior fills or documented diagnoses within specified lookback windows; if the required prior therapy is not documented, a prior authorization is required to process the claim.
Definitions
Initial Therapy Criteria
GLP-1 initial therapy
Initial therapy — covered when ONE of the following is documented in the Independent Health pharmacy history:
Applies to listed GLP-1 products; absence requires prior authorization.
Tramadol ER initial therapy
Initial therapy — covered when ALL of the following are met:
If not documented, prior authorization is required.
Step Therapy Operational Table
| Step therapy enforcement |
|---|
| Step therapy is enforced by checking the member's Independent Health pharmacy history for required prior fills of specified medications within each product-specific lookback window; absence of the required history triggers prior authorization. |
| Product | Required pharmacy documentation | Action if not documented |
|---|---|---|
| {"text":"Serevent Diskus (salmeterol)","status":""}|{"text":"Pharmacy profile documents concurrent use of an inhaled corticosteroid OR tiotropium (Spiriva)","status":""}|{"text":"Prior authorization required if concurrent controller not documented; claim will not route online","status":""} |
| Product | Required pharmacy documentation | Lookback window / Action if not documented |
|---|---|---|
| {"text":"Tramadol extended‑release preparations","status":""}|{"text":"Pharmacy history documents an immediate‑release tramadol fill","status":""}|{"text":"90 days lookback — prior authorization required if not documented","status":""} |
| Product | Required pharmacy documentation | Lookback window / Action if not documented |
|---|---|---|
| {"text":"Ubrelvy (ubrogepant)","status":""}|{"text":"Pharmacy history documents a generic triptan (e.g., sumatriptan, naratriptan, rizatriptan)","status":""}|{"text":"120 days lookback — prior authorization required if not documented","status":""} |
| Product | Required pharmacy documentation | Lookback window / Action if not documented |
|---|---|---|
| {"text":"Febuxostat (Uloric)","status":""}|{"text":"Pharmacy history documents an allopurinol fill","status":""}|{"text":"90 days lookback — prior authorization required if not documented","status":""} |
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