Step therapy prior‑authorization requirement

Prior authorization requires documentation of failure or trial of the specified first-line agent(s) listed for each product before covering the requested product.

Try an ARB before aliskiren 300 mg

Aliskiren fumarate 300 mg is subject to step therapy and requires prior use of an angiotensin‑II receptor blocker (ARB) before coverage.

Aripiprazole formulation sequencing

Sequencing across aripiprazole formulations is required: aripiprazole oral solution must be used before the orally‑disintegrating tablet (ODT), and the ODT must be used before aripiprazole oral films.

• Aripiprazole oral solution → Aripiprazole ODT
• Aripiprazole ODT → Aripiprazole oral films

Topical corticosteroid or calcineurin inhibitor required first

EUCRISA (crisaborole) ointment requires prior use of either a topical corticosteroid or a topical calcineurin inhibitor before coverage.

• Either a topical corticosteroid OR a topical calcineurin inhibitor satisfies the step

Try allopurinol before febuxostat 80 mg

Febuxostat 80 mg requires prior use of allopurinol before febuxostat will be covered.

Clobazam oral suspension required before SYMPAZAN films

SYMPAZAN films require prior use of clobazam oral suspension before coverage of the film formulation.

Try Lupron Depot before TRELSTAR injections

TRELSTAR injectable formulations require prior use of Lupron Depot before coverage of TRELSTAR injections.

Clozapine ODT required before VERSACLOZ suspension

VERSACLOZ oral suspension requires prior use of clozapine orally‑disintegrating tablet (ODT) before coverage.

Try calcitriol before doxercalciferol capsules

Doxercalciferol capsules require prior use of calcitriol before coverage will be provided.

Denial risk if ARB not tried before aliskiren 300 mg

Coverage may be denied if the required prior step (an angiotensin‑II receptor blocker) is not tried before aliskiren fumarate 300 mg.

Enforce aripiprazole formulation sequence

Aripiprazole oral solution must be tried before aripiprazole ODT, and aripiprazole ODT must be used before aripiprazole oral films; failure to follow sequencing may affect coverage.

• Solution → ODT → Oral films

EUCRISA requires prior topical steroid or calcineurin inhibitor

Topical corticosteroid or topical calcineurin inhibitor must be used before EUCRISA (crisaborole) ointment; lack of prior use may lead to noncoverage.

Denial risk if allopurinol not tried before febuxostat 80 mg

Allopurinol must be tried before febuxostat 80 mg; coverage for febuxostat 80 mg is contingent on prior allopurinol use.

SYMPAZAN requires prior clobazam suspension

Clobazam oral suspension must be used before SYMPAZAN films; failure to try the suspension first may prevent coverage of the film.

TRELSTAR coverage contingent on prior Lupron Depot

Lupron Depot must be used before TRELSTAR injectable formulations; absence of prior Lupron Depot use may result in denial.

VERSACLOZ requires prior clozapine ODT

Clozapine ODT must be used before VERSACLOZ oral suspension; coverage depends on prior use of the ODT formulation.

Doxercalciferol coverage requires prior calcitriol

Calcitriol must be used before doxercalciferol capsules; lack of prior calcitriol therapy may lead to noncoverage.

Member services and formulary notice

For questions about formulary rules or coverage, contact Medicare Member Services at 1-800-667-5936 (TTY 711). The formulary may change and members will be notified.