Step Therapy Criteria — Medicare Advantage Standard Part D Formulary
Customize your policy alerts
Sign up for all Independent Health policy alerts
Know when Independent Health releases new policies or updates existing guidance.
Monitor payer policy activity
Defines step therapy requirements for specific drugs on Independent Health's 2026 Medicare Advantage Standard Part D formulary; affects providers prescribing and pharmacists processing Part D claims for members covered under this formulary.
No material clinical or coverage changes in this revision.
Product-specific Step Therapy Criteria
Aliskiren (300 mg) step requirement
aliskiren fumarate tablet 300 mg requires prior use of an ARB
Supports aliskiren fumarate 300 mg oral
Aripiprazole sequencing
Aripiprazole formulations sequencing
Applies to ODT presentations
Applies to OPIPZA film products
EUCRISA
EUCRISA step requirement
Topical nonsteroidal alternatives required before EUCRISA
Febuxostat
Febuxostat step requirement
Applies to both 40 mg and 80 mg strengths
SYMPAZAN
SYMPAZAN films sequencing
Applies to 5 mg, 10 mg, 20 mg film presentations
TRELSTAR MixJect
TRELSTAR MixJect sequencing
Applies to listed reconstituted intramuscular presentations
VERSACLOZ and doxercalciferol
Clozapine and doxercalciferol sequencing
Applies to clozapine suspension
Applies to 0.5, 1, and 2.5 mcg presentations as indexed
Required First-line Agents
Initial therapy requirements
Required first-line agents for select products
From Details chunk
Aripiprazole initial therapy
Aripiprazole initial therapy
From Details chunk
Step Requirements and Required Prior Agents
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| EUCRISA ointment 2% (external) | Topical corticosteroid or topical calcineurin inhibitor | Requires trial of a topical corticosteroid or topical calcineurin inhibitor before coverage of EUCRISA (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| Febuxostat tablet 40 mg | Allopurinol | Requires trial of allopurinol before coverage of febuxostat 40 mg (step 1) |
| Febuxostat tablet 80 mg | Allopurinol | Requires trial of allopurinol before coverage of febuxostat 80 mg (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| SYMPAZAN film (5 mg, 10 mg, 20 mg) | Clobazam oral suspension | Requires trial of clobazam oral suspension before coverage of SYMPAZAN films (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| TRELSTAR MixJect suspension (3.75 mg, 11.25 mg, 22.5 mg IM recon. presentations) | Lupron Depot | Requires trial of Lupron Depot before coverage of TRELSTAR MixJect suspensions (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| VERSACLOZ suspension 50 mg/mL oral | Clozapine orally-disintegrating tablet (ODT) | Requires trial of clozapine ODT before coverage of VERSACLOZ suspension (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| Doxercalciferol capsule 2.5 mcg oral | Calcitriol | Requires trial of calcitriol before coverage of doxercalciferol 2.5 mcg capsule (step 1) |
| Drug | Required first-step therapy | Coverage |
|---|---|---|
| Aliskiren fumarate tablet 300 mg oral | Angiotensin-II receptor blocker (ARB) | Requires trial of an ARB before coverage of aliskiren fumarate 300 mg (step 1) |
What Providers and Pharmacists Must Do
Step therapy may require prior authorization for Part D formulary
Step therapy protocols apply to the Medicare Advantage Part D formulary and may require prior authorization when the member has not met step requirements; this list pertains to Independent Health's 2026 Medicare Advantage Standard Part D Formulary and contains the associated Step Therapy protocols.
- Contact Medicare Member Services with questions: 1-800-665-1502 (TTY 711).
Overview — product-level required first-line therapies
Specific product-level first-line therapies are required before coverage of listed non-preferred products; see the per-product entries in this policy (coverage.module and drug_policy) for the required first-step agents (for example: ARB before aliskiren 300 mg; topical corticosteroid or topical calcineurin inhibitor before EUCRISA; allopurinol before febuxostat; clobazam oral suspension before SYMPAZAN films; Lupron Depot before TRELSTAR MixJect; clozapine ODT before VERSACLOZ; calcitriol before doxercalciferol).
Document prior use and inadequate response or intolerance
When requesting coverage for a non-preferred product under step therapy, providers should document prior use and either inadequate response or intolerance to the required first-line agent(s).
- Documentation should show trial of the required first-step agent(s) and reason for failure (intolerance or inadequate response).
Noncompliance with step therapy can lead to claim denial
Claims may be denied or not covered if step therapy requirements are not met; prescribers must ensure required first-step agents were tried and documented before submitting claims for non-preferred products.
- Failure to meet step requirements (e.g., not trying the specified first-line agent) can result in denial of coverage for the requested drug.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.