Step Therapy Criteria — Medicare Advantage Part D Formularies
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Defines step therapy protocols requiring trial of specified first-line drugs before coverage of listed products for Independent Health's 2026 Medicare Advantage Part D formulary members. Applies to providers prescribing the listed drugs for affected Medicare Advantage C-SNP Part D members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Affected Products
Aliskiren 300 mg initial criteria
Covered when ALL of the following are met:
Supports coverage of aliskiren 300 mg after ARB failure
Aripiprazole formulation sequencing
Covered when ALL of the following are met:
ODT requires prior solution
Film requires prior ODT
EUCRISA
Covered when ALL of the following are met:
Either class acceptable as first-line topical therapy
Febuxostat
Covered when ALL of the following are met:
All febuxostat strengths require prior allopurinol
SYMPAZAN films
Covered when ALL of the following are met:
All SYMPAZAN film strengths require prior clobazam suspension
TRELSTAR MixJect
Covered when ALL of the following are met:
Applies to listed MixJect strengths
Versacloz and doxercalciferol
Covered when ALL of the following are met:
Supports coverage of Versacloz suspension
All listed doxercalciferol strengths require prior calcitriol
This policy does not list any product-level exclusions beyond the step therapy sequencing requirements described for specific drugs. It applies to the Independent Health 2026 Medicare Advantage C‑SNP Part D formulary and defines step therapy expectations that must be met before coverage is approved for the listed products.
Provider Requirements and Documentation
Step therapy prior authorization requirement
Prior authorization requires documentation of trial and inadequate response or intolerance to the specified first-line drug(s) listed for each affected product before coverage of the requested product.
Aliskiren 300 mg requires ARB first
Aliskiren fumarate 300 mg requires a prior trial of an angiotensin-II receptor blocker (ARB) before coverage is approved.
Aripiprazole ODT/film sequencing
Aripiprazole ODT requires prior use of aripiprazole oral solution; aripiprazole oral films require prior use of aripiprazole ODT before coverage.
EUCRISA requires topical steroid or calcineurin inhibitor first
EUCRISA ointment 2% requires prior use of either a topical corticosteroid or a topical calcineurin inhibitor before coverage.
Febuxostat requires allopurinol first
Febuxostat tablets (40 mg and 80 mg) require documented prior use of allopurinol before coverage will be granted.
SYMPAZAN films require clobazam suspension first
SYMPAZAN films (all strengths listed) require prior use of clobazam oral suspension before coverage.
TRELSTAR requires Lupron Depot first
TRELSTAR MixJect formulations require prior use of Lupron Depot before coverage of the MixJect products.
Versacloz and doxercalciferol sequencing
VERSACLOZ suspension requires prior use of clozapine ODT; doxercalciferol capsules require prior use of calcitriol before coverage.
Aliskiren 300 mg documentation
Document the prior trial and the outcome (inadequate response or intolerance) of ARB therapy when requesting coverage for aliskiren fumarate 300 mg.
Aripiprazole sequencing documentation
Document prior use of aripiprazole oral solution before approving aripiprazole ODT, and document prior use of aripiprazole ODT before approving aripiprazole oral films.
EUCRISA documentation
Document prior use of a topical corticosteroid or a topical calcineurin inhibitor when requesting coverage for EUCRISA ointment 2%.
Febuxostat documentation
Document prior use of allopurinol (trial and outcome) for requests for febuxostat tablets (40 mg and 80 mg).
SYMPAZAN documentation
Document prior use of clobazam oral suspension for requests for SYMPAZAN films (all strengths).
TRELSTAR documentation
Document prior use of Lupron Depot (trial and outcome) for requests for TRELSTAR MixJect formulations.
Versacloz and doxercalciferol documentation
Document prior use of clozapine ODT for Versacloz suspension requests and prior use of calcitriol for doxercalciferol capsule requests.
Aliskiren 300 mg denial risk
Coverage for aliskiren fumarate 300 mg requires prior use of an angiotensin-II receptor blocker (ARB); failure to document a prior ARB trial may result in denial.
Aripiprazole ODT/film sequencing denial risk
Coverage for aripiprazole ODT and films requires documented trials of the specified prior formulations (oral solution before ODT, ODT before film); lack of those prior trials may lead to denial.
EUCRISA denial risk
Coverage for EUCRISA ointment requires prior use of a topical corticosteroid or topical calcineurin inhibitor; absence of such a trial may risk denial.
Febuxostat denial risk
Coverage for febuxostat tablets (40 mg and 80 mg) requires prior use of allopurinol; failure to document prior allopurinol use may trigger denial.
SYMPAZAN denial risk
Coverage for SYMPAZAN films requires prior use of clobazam oral suspension; absence of documentation of prior clobazam suspension use may result in denial.
TRELSTAR denial risk
Coverage for TRELSTAR MixJect formulations requires prior use of Lupron Depot; lack of prior Lupron Depot use may cause denial.
Versacloz and doxercalciferol sequencing denial risk
Coverage for VERSACLOZ suspension requires prior use of clozapine ODT and coverage for doxercalciferol capsules requires prior use of calcitriol; missing documentation of these prior therapies may lead to denial.
Key Definitions
Initial Therapy Requirements
Initial therapy requirements
Initial step therapy requirements for listed drugs
Applies to aliskiren 300 mg only
Step Therapy Matrix
| Requested drug | Required prior therapy | Coverage status |
|---|---|---|
| aliskiren fumarate tablet 300 mg oral | ||
| Trial and inadequate response or intolerance to an angiotensin-II receptor blocker (ARB) | ||
| Covered with step therapy requirement: ARB first |
| Requested drug/formulation | Required prior formulation | Coverage status |
|---|---|---|
| Aripiprazole orally-disintegrating tablet (ODT) | ||
| Aripiprazole oral solution (trial and inadequate response or intolerance) | ||
| Covered with step therapy requirement: solution before ODT | ||
| Aripiprazole oral film | ||
| Aripiprazole ODT (trial and inadequate response or intolerance) | ||
| Covered with step therapy requirement: ODT before film |
| Requested drug | Required prior therapy | Coverage status |
|---|---|---|
| EUCRISA ointment 2% | ||
| Trial and inadequate response or intolerance to either a topical corticosteroid or a topical calcineurin inhibitor | ||
| Covered with step therapy requirement: topical steroid or topical calcineurin inhibitor first |
| Requested drug (strengths) | Required prior therapy | Coverage status |
|---|---|---|
| febuxostat tablet 40 mg; febuxostat tablet 80 mg | ||
| Trial and inadequate response or intolerance to allopurinol | ||
| Covered with step therapy requirement: allopurinol first |
| Requested drug (strengths) | Required prior therapy | Coverage status |
|---|---|---|
| SYMPAZAN film (5 mg, 10 mg, 20 mg) | ||
| Trial and inadequate response or intolerance to clobazam oral suspension | ||
| Covered with step therapy requirement: clobazam oral suspension first |
| Requested drug (MixJect strengths) | Required prior therapy | Coverage status |
|---|---|---|
| TRELSTAR MixJect suspension (3.75 mg; 11.25 mg; 22.5 mg recon) | ||
| Trial and inadequate response or intolerance to Lupron Depot | ||
| Covered with step therapy requirement: Lupron Depot first |
| Requested drug | Required prior therapy | Coverage status |
|---|---|---|
| VERSACLOZ suspension 50 mg/mL | ||
| Trial and inadequate response or intolerance to clozapine orally-disintegrating tablet (ODT) | ||
| Covered with step therapy requirement: clozapine ODT first | ||
| Doxercalciferol capsules (0.5 mcg, 1 mcg, 2.5 mcg) | ||
| Trial and inadequate response or intolerance to calcitriol | ||
| Covered with step therapy requirement: calcitriol first |
Background and Rationale
Step therapy (fail‑first) requires a trial of a clinically appropriate first‑line therapy specified in this document before the requested alternative product will be covered. The intent is to ensure members try standard, lower‑tier, or formulary preferred agents first and to permit coverage of the requested drug only when the member has had an inadequate response or intolerance to the required prior therapy. Providers must document the prior trial and the outcome when submitting a prior authorization request.
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