Independent Health step therapy Coverage Update | OpenPayer

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Independent Health step therapy Coverage Update | OpenPayer

Provider Actions and Prior Treatment Requirements

Prior Authorization

Aliskiren — ARB trial required

Aliskiren products require a prior prescription history showing trial of an angiotensin receptor blocker (ARB) before coverage will be approved.

Affected products: aliskiren fumarate 150 mg and 300 mg tablets
Documentation: prior ARB prescription history must be provided

Prior Authorization

Febuxostat — allopurinol trial required

Febuxostat (ULORIC) requires prior use of allopurinol before febuxostat will be covered.

Affected products: febuxostat 40 mg and 80 mg tablets
Documentation: prior allopurinol trial must be documented

Step Therapy

Pregabalin ER — IR pregabalin trial required

Pregabalin extended‑release (ER) products require prior use of an immediate‑release (IR) pregabalin formulation before coverage of ER formulations.

Affected product example: pregabalin ER 24‑hour 82.5 mg tablet
Documentation: prior IR pregabalin prescription history must be supplied

Prior Authorization

EUCRISA — prior topical therapy required

EUCRISA (crisaborole) coverage requires prior prescription history showing use of a topical corticosteroid or a topical calcineurin inhibitor.

Documentation: prior topical corticosteroid or topical calcineurin inhibitor trial must be provided

Prior Authorization

FINACEA — prior topical rosacea therapy required

FINACEA (topical azelaic acid for rosacea) requires prior use of at least one other topical rosacea medication for papules/pustules (for example azelaic acid gel, ivermectin cream, or metronidazole products) before coverage.

Affected product: FINACEA topical formulation
Documentation: prior topical rosacea medication trial must be documented

Prior Authorization

TALICIA — prior H. pylori regimen required

TALICIA coverage requires prior prescription history demonstrating failure or trial of an empiric (standard first‑line) Helicobacter pylori regimen prior to approval.

Affected product: TALICIA
Documentation: prior standard H. pylori regimen (e.g., clarithromycin‑based or bismuth‑based therapy per guideline/standard of care) must be documented

Prior Authorization

Doxercalciferol — prior calcitriol required

Doxercalciferol coverage requires prior prescription history showing prior use of calcitriol.

Affected product: doxercalciferol 2.5 mcg capsule
Documentation: prior calcitriol prescription history must be provided

Step Therapy

Qelbree — prior atomoxetine required

Qelbree (viloxazine extended‑release) requires prior use of generic atomoxetine before coverage of Qelbree is approved.

Affected product: Qelbree extended‑release 200 mg capsule
Documentation: prior generic atomoxetine trial must be documented

Note

Member Services Contact

For questions about step therapy protocols or to submit documentation of prior therapies, contact Medicare Member Services at the numbers listed for Pharmacy Benefit Dimensions / Independent Health.

Use the Member Services contact to ask about step therapy requirements or where to send supporting documentation

Step Therapy Overview and Table

Drug / Product	Required prior therapy (documented in prescription history)	Coverage status
aliskiren fumarate tablet 150 mg; aliskiren fumarate tablet 300 mg
Prior prescription history of an angiotensin receptor blocker (ARB)
Covered with criteria