CurrentIndependent HealthPolicy N/A

Step therapy criteria for Medicare Part D formulary drugs

Defines step therapy requirements for specific drugs on Independent Health's 2026 Medicare Advantage Standard Part D formulary; affects prescribers and pharmacists serving members under that formulary.

Policy Summary

PayerIndependent Health

PolicyStep therapy criteria for Medicare Part D formulary drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective Dateas of 2026-05-01

Next Review DateN/A

Key ActionConfirm patients have trialed the specified first-line therapy (e.g., ARB before aliskiren 300 mg) before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈15listed products or product lines

2026-05-01step therapy list current as of

Medicare Part Dformulary type governed

Step Therapy Coverage Criteria

Aliskiren 300 mg

Covered when prior therapy requirement is met:

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Provider/Prescriber Actions & Prior Therapy Requirements

Note

Member / Provider contact & formulary notice

This policy includes step-therapy and sequencing requirements that may affect prescribing and prior authorization. See specific product callouts below for the required prior therapy or sequencing that must be documented before coverage will be approved.

Medicare Member Services: 1-800-665-1502; TTY 711.
Hours: Oct 1–Mar 31: daily 8 a.m.–8 p.m.; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m.

Step Therapy

Aliskiren 300 mg — ARB prior therapy required

Aliskiren 300 mg requires documented prior trial and failure (or intolerance) of an angiotensin-II receptor blocker (ARB) before coverage will be considered.

Affected product: aliskiren fumarate tablet 300 mg oral.
Prior therapy required: trial of an ARB (document agent, dates, and clinical response).

Step Therapy

Aripiprazole ODT/film sequencing — prior aripiprazole formulation required

Aripiprazole dispersible tablets and oral films are subject to sequencing requirements: ODT and film presentations require prior use of other aripiprazole formulations in a specified order.

Affected products: aripiprazole tablet dispersible 10 mg and 15 mg; OPIPZA film products (2 mg, 5 mg, 10 mg).
Sequencing: Aripiprazole orally-disintegrating tablet (ODT) requires prior use of aripiprazole oral solution. Aripiprazole oral films require prior use of aripiprazole ODT (document prior product, dates, and clinical rationale).

Step Therapy

EUCRISA Ointment — topical corticosteroid or calcineurin inhibitor required first

EUCRISA Ointment 2% requires prior use of a topical corticosteroid or a topical calcineurin inhibitor before coverage will be approved.

Affected product: EUCRISA OINTMENT 2% EXTERNAL.
Prior therapy required: trial of a topical corticosteroid or a topical calcineurin inhibitor (document agent, duration, and outcome).

Step Therapy

Febuxostat — allopurinol prior therapy required

Febuxostat (all strengths listed) requires a prior trial of allopurinol before coverage will be considered.

Affected product example: febuxostat tablet 80 mg oral (all febuxostat strengths subject to step therapy).
Prior therapy required: trial of allopurinol (document dose, duration, and response/intolerance).

Step Therapy

SYMPAZAN film — prior clobazam oral suspension required

SYM P A Z A N (film) requires prior use of clobazam oral suspension before the film formulation will be covered.

Affected product: SYMPAZAN FILM 5 mg oral.
Prior therapy required: clobazam oral suspension (document prior use, dates, and clinical response).

Step Therapy

Doxercalciferol — calcitriol prior therapy required

Doxercalciferol products require prior use of calcitriol before coverage of certain strengths will be approved.

Affected products: doxercalciferol capsules 0.5 mcg, 1 mcg, and 2.5 mcg (2.5 mcg specifically requires calcitriol first).
Prior therapy required: trial of calcitriol (document agent, dose, duration, and reason for failure/intolerance).

Background and Rationale

Step therapy is a utilization-management protocol used on Independent Health's Medicare Advantage Part D formulary that requires members to try specified first‑line therapies before certain alternative agents will be covered. The intent is to ensure clinically appropriate, cost‑effective sequencing of treatments: if the required first‑line drug is ineffective or not tolerated, the plan will then consider coverage of the alternative agent.

This document lists the product‑specific step therapy requirements in effect as of 2026-05-01, and identifies the affected products and the required prior therapy for each. Examples include: aliskiren fumarate 300 mg which requires prior use of an angiotensin‑II receptor blocker (ARB); aripiprazole formulations where the ODT requires prior use of oral solution and films require prior use of the ODT; and EUCRISA Ointment 2% which requires prior use of either a topical corticosteroid or a topical calcineurin inhibitor.

Providers and pharmacists should verify prior therapy history when submitting for coverage of step‑therapy listed products. Members or providers with questions may contact Medicare Member Services at the numbers listed in the formulary materials; note that the formulary and associated protocols may change and members will be notified when necessary.

Definitions

Step Therapy definition — inv-30

DefinitionA protocol requiring patients to try specified first-line therapies before alternative drugs will be covered under the formulary.

PurposeUsed as a utilization‑management tool on the Medicare Advantage Part D formulary to ensure preferred sequencing of therapies.

Provider actionPrescribers must document prior trial(s) of the required first‑line agent(s) (per product‑specific step therapy rules) to obtain coverage for the subsequent agent.

ScopeApplies to drugs listed on Independent Health’s 2026 Medicare Advantage Standard Part D formulary subject to step therapy (see product‑specific entries).

Member supportMembers or providers with questions may contact Medicare Member Services at 1‑800‑665‑1502 (TTY 711) for assistance.

Step Therapy Summary Table

Drug	Step therapy requirement	Coverage status
Aliskiren fumarate 300 mg (tablet)
Requires prior use of an angiotensin-II receptor blocker (ARB)
Covered with criteria

Product	Sequencing requirement	Coverage status
Aripiprazole orally-disintegrating tablet (ODT)
Requires prior use of aripiprazole oral solution
Covered with criteria
Aripiprazole oral films (Opipza films)
Require prior use of aripiprazole ODT
Covered with criteria

Product	Prerequisite therapy	Coverage status
EUCRISA Ointment 2%
Requires prior use of either a topical corticosteroid or a topical calcineurin inhibitor
Covered with criteria

Drug	Required prior agent	Coverage status
Febuxostat 40 mg and 80 mg (tablets)
Requires prior use of allopurinol
Covered with criteria

Product	Prior therapy required	Coverage status
SYMPAZAN oral films (5 mg, 10 mg, 20 mg)
Requires prior use of clobazam oral suspension
Covered with criteria

Product	Required prior GnRH agonist	Coverage status
Trelstar Mixject (listed IM strengths)
Requires prior use of Lupron Depot
Covered with criteria

Product	Prior clozapine formulation required	Coverage status
Versacloz suspension (50 mg/mL)
Requires prior use of clozapine orally-disintegrating tablet (ODT)
Covered with criteria

Product	Required prior agent	Coverage status
Doxercalciferol capsules (0.5 mcg, 1 mcg, 2.5 mcg)
Requires prior use of calcitriol
Covered with criteria

Policy Summary

PayerIndependent Health

PolicyStep therapy criteria for Medicare Part D formulary drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective Dateas of 2026-05-01

Next Review DateN/A

Key ActionConfirm patients have trialed the specified first-line therapy (e.g., ARB before aliskiren 300 mg) before requesting coverage.

SourceLink

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