Step therapy criteria for formulary medications
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Defines step therapy requirements for medications on Independent Health 2026 formularies and explains when prior authorization is required based on a member's prescription history; applies to providers, pharmacies, and members covered under Independent Health formularies.
No material clinical or coverage changes in this revision.
Product-specific Coverage and Routing Rules
Product-specific step therapy coverage
Covered when ALL of the following are met for the specific product:
If this condition is not met, prior authorization is required.
Automated prior-fill coverage pass
Covered (passes online) when ANY one prior-fill condition is met for the specific product within its lookback window; otherwise prior authorization is required.
If this condition is true the prescription 'goes through online' and PA is not required.
Initial Processing Criteria (Fill-history based)
Covered when ALL of the following are met for each product entry:
If this condition is not met prior authorization is required
Trintellix routing criteria
Covered when conditions in routing criteria are met; otherwise prior authorization required
If criterion not met, prior authorization required
Febuxostat routing criteria
If criterion not met, prior authorization required
Xphozah routing criteria
If not documented, prescriber may request authorization via standard process
Zolpidem sublingual routing criteria
If criterion not met, prior authorization required
Starting any of the listed high‑potency narcotics in a patient with no recent narcotic use will trigger prior authorization. Specifically, these products will only "go through online" (process without prior authorization) when the member's Independent Health pharmacy history documents a narcotic medication fill within the previous 120 days. If the pharmacy profile does not show a qualifying narcotic fill in that lookback window, prior authorization is required before the prescription can be dispensed.
For aliskiren entries, the claim will only process online when the member's Independent Health pharmacy history documents fills for both an ACE inhibitor and an ARB within the previous 180 days. If the pharmacy profile does not show both an ACE and an ARB filled in that 180‑day lookback, prior authorization is required.
Affected Product Listings and Lookback Windows
| EUCRISA OINTMENT 2 % EXTERNAL | product listed |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL | product listed |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL | product listed |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 40 MG | product listed |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL | product listed |
| FETZIMA TITRATION CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG ORAL | product listed |
| glycopyrrolate soluon 1 mg/5ml oral | product listed |
| doxercalciferol capsule 0.5 mcg oral | product listed |
| doxercalciferol capsule 1 mcg oral | product listed |
| doxercalciferol capsule 2.5 mcg oral | product listed |
| RAYALDEE CAPSULE EXTENDED RELEASE 30 MCG ORAL | product listed |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 12.5 mg oral | product listed |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 25 mg oral | product listed |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 37.5 mg oral | product listed |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 50 mg oral | product listed |
| memanne hcl-donepezil hcl er capsule extended release 24 hour 14-10 mg oral | product listed |
| memanne hcl-donepezil hcl er capsule extended release 24 hour 21-10 mg oral | product listed |
| memanne hcl-donepezil hcl er capsule extended release 24 hour 28-10 mg oral | product listed |
| NAMZARIC CAPSULE EXTENDED RELEASE 24 HOUR 7-10 MG ORAL | product listed |
| fentanyl patch 72 hour 100 mcg/hr transdermal | product listed |
| fentanyl patch 72 hour 12 mcg/hr transdermal | product listed |
| fentanyl patch 72 hour 25 mcg/hr transdermal | product listed |
| fentanyl patch 72 hour 50 mcg/hr transdermal | product listed |
| fentanyl patch 72 hour 75 mcg/hr transdermal | product listed |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 100 mg oral | product listed |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 120 mg oral | product listed |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 20 mg oral | product listed |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 30 mg oral | product listed |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 40 mg oral | product listed |
| ONGENTYS CAPSULE 25 MG ORAL | product listed |
| ONGENTYS CAPSULE 50 MG ORAL | product listed |
| ORAVIG TABLET 50 MG BUCCAL | product listed |
| oxcarbazepine er tablet extended release 24 hour 150 mg oral | product listed |
| oxcarbazepine er tablet extended release 24 hour 300 mg | product listed |
| oxcarbazepine er tablet extended release 24 hour 600 mg oral | Product listed |
| QELBREE CAPSULE EXTENDED RELEASE 24 HOUR 100 MG ORAL | Product listed |
| QELBREE CAPSULE EXTENDED RELEASE 24 HOUR 150 MG | Product listed |
| QELBREE CAPSULE EXTENDED RELEASE 24 HOUR 200 MG ORAL | Product listed |
| QUILLICHEW ER TABLET CHEWABLE EXTENDED RELEASE 20 MG ORAL | Product listed |
| QUILLICHEW ER TABLET CHEWABLE EXTENDED RELEASE 30 MG ORAL | Product listed |
| QUILLICHEW ER TABLET CHEWABLE EXTENDED RELEASE 40 MG ORAL | Product listed |
| QUILLIVANT XR SUSPENSION RECONSTITUTED ER 25 MG/5ML ORAL | Product listed |
| aliskiren fumarate tablet 150 mg oral | Product listed |
| aliskiren fumarate tablet 300 mg oral | Product listed |
| SANCUSO PATCH 3.1 MG/24HR TRANSDERMAL | Product listed |
| SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT INHALATION | Product listed |
| tazarotene cream 0.05 % external | Product listed |
| tazarotene cream 0.1 % external | Product listed |
| tazarotene gel 0.05 % external | Product listed |
| tazarotene gel 0.1 % external | Product listed |
| tramadol hcl er tablet extended release 24 hour 100 mg oral | Product listed |
| tramadol hcl er tablet extended release 24 hour 200 mg | Product listed |
| tramadol hcl er tablet extended release 24 hour 300 mg oral | Product listed |
| TRINTELLIX TABLET 10 MG ORAL | Product listed |
| TRINTELLIX TABLET 20 MG ORAL | Product listed |
| TRINTELLIX TABLET 5 MG ORAL | Product listed |
| febuxostat tablet 40 mg oral | product listed |
| febuxostat tablet 80 mg oral | product listed |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
Prior Authorization Triggers and Required Documentation
Prior Authorization Triggers and Required Documentation
Prior authorization is required when the member's Independent Health pharmacy profile does not document the specified prior fill or concurrent medication within the product-specific lookback window. When the required fill(s) are present in the Independent Health prescription history within the stated lookback period, the prescription will process online without a prior authorization.
- EUCRISA: PA required if no generic NSAID fill in prior 180 days.
- Topical immunomodulator/corticosteroid products: PA required if no tacrolimus, pimecrolimus, or topical corticosteroid fill in prior 365 days.
- Glycopyrrolate products: PA required if no generic glycopyrrolate tablet fill in prior 90 days.
- Doxercalciferol products: PA required if no calcitriol fill in prior 90 days.
- Amphetamine–dextroamphetamine ER products: PA required if no amphetamine–dextroamphetamine ER capsule fill in prior 90 days.
- Memantine/donepezil combination products (e.g., Namzaric): PA required if no donepezil or memantine fill in prior 90 days.
- High‑potency extended‑release narcotics: PA required if no narcotic medication fill in prior 120 days.
- Formulary notes: Medications that require step therapy are marked with 'ST' in the formulary; contact Member Services at 1-800-501-3439 (TTY 711) for questions.
- Automated fill-history step checks: prescriptions will "go through online" (no PA) when the patient's Independent Health prescription history documents the required prior fills or concurrent therapies within the product-specific lookback windows.
- Fill-history step rules: each listed product has a step‑therapy style rule — the prescription processes without PA only if the Independent Health pharmacy profile shows the qualifying prior fill(s) within the specified lookback period; otherwise prior authorization must be submitted.
Fill-History Based Initial Processing Rules
Dapsone gel (Aczone) initial requirement
Initial pharmacy-fill-based step requirement
If not documented, prior authorization is required.
Belsomra initial requirement
Initial pharmacy-fill-based step requirement
If not documented, prior authorization is required.
Initial therapy screening
Initial dispensing decision based on recent pharmacy history
If absent, prior authorization required.
Clotrimazole/Fluconazole/Nystatin rule
Processing allowed without prior authorization when prior-fill criteria met
If met, prescription processes online; if not, prior authorization required.
Oxcarbazepine rule
If met, prescription processes online; otherwise prior authorization required.
Methylphenidate SR/XR rule
If met, prescription processes online; otherwise prior authorization required.
Aliskiren rule
If met, prescription processes online for aliskiren; otherwise prior authorization required.
Sancuso rule
If met, Sancuso patch processes online; otherwise prior authorization required.
Serevent Diskus rule
If met, Serevent Diskus processes online; otherwise prior authorization required.
Tazarotene topical rule
If met, tazarotene topical products process online; otherwise prior authorization required.
Tramadol ER rule
If met, tramadol ER processes online; otherwise prior authorization required.
Trintellix rule
If met, Trintellix processes online; otherwise prior authorization required.
Febuxostat (Uloric) rule
If met, febuxostat (Uloric) processes online; otherwise prior authorization required.
Trintellix initial therapy
Routing based on prior medication fills
Febuxostat initial therapy
Xphozah initial therapy
Zolpidem sublingual initial therapy
Step Requirements and Exceptions
| Step requirement | Notes |
|---|---|
| Trial of an oral antidiabetic agent (excluding metformin) or documentation of type 2 diabetes in the member's Independent Health prescription history | Lookback window: 130 days; if criterion not met, prior authorization is required. |
| Coverage passes online when history shows type 2 diabetes or a trial of any oral antidiabetic (excl. metformin) | Source criteria: GLP-1 product routing based on prior-fill documentation. |
| Step requirement | Notes |
|---|---|
| Concurrent use of a levodopa/carbidopa product documented in the member's Independent Health prescription history | If concurrent levodopa/carbidopa use is not documented, prior authorization is required. |
| Step requirement | Notes |
|---|---|
| Trial of a generic nonsteroidal anti-inflammatory drug (NSAID) documented in pharmacy history | Lookback window: previous 180 days; absence of a generic NSAID fill triggers prior authorization. |
| Step requirement | Notes |
|---|---|
| Documented fill of the specified comparator or prerequisite medication within the product-specific lookback window | Lookback window varies by product (commonly 30–365 days); if no qualifying prior fill is present, prior authorization is required. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | A prescription will not pass automated online processing when the pharmacy profile does not show the specified prior fill within the lookback window. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If no oxcarbazepine fill is documented within the previous 90 days, the claim requires prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If no generic methylphenidate SR/XR fill is documented within the previous 120 days, prior authorization is required. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If ACE and ARB fills are not both documented within the previous 180 days for aliskiren entries, the prescription requires prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If ondansetron is not documented within the previous 180 days, the Sancuso patch claim will require prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If concurrent inhaled corticosteroid or tiotropium (Spiriva) use is not documented, Serevent Diskus will require prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If tretinoin or adapalene is not documented within the previous 90 days, tazarotene topical products require prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If immediate‑release tramadol is not documented within the previous 90 days, tramadol ER prescriptions require prior authorization. |
| Step outcome | Action when criterion not met |
|---|---|
| Prior authorization required | If the required generic SSRI (for Trintellix) or allopurinol (for febuxostat) fill is not documented within the prior 90 days, prior authorization is required. |
| Trintellix requirement | Notes |
|---|---|
| Documented generic SSRI fill within the previous 90 days required to avoid prior authorization | Trintellix 5 mg is routed online only when pharmacy history documents a generic SSRI (e.g., sertraline, fluoxetine, escitalopram) filled within 90 days; otherwise PA required. |
| Febuxostat requirement | Notes |
|---|---|
| Documented allopurinol fill within the previous 90 days required to avoid prior authorization | Febuxostat (Uloric) 40 mg and 80 mg route online when an allopurinol fill is documented within 90 days; otherwise PA required. |
| Xphozah requirement | Notes |
|---|---|
| Documented concurrent phosphate binder use within the previous 120 days required to avoid prior authorization | If concurrent phosphate binder use is not documented, prescriber may request authorization via the standard process. |
| Zolpidem sublingual requirement | Notes |
|---|---|
| Documented generic zolpidem fill within the previous 90 days required to avoid prior authorization | Sublingual zolpidem (1.75 mg and 3.5 mg) is routed online only if a generic zolpidem fill is present within 90 days; otherwise PA required. |
Policy Rationale and Definitions
Step therapy is a utilization management approach that encourages trial of established, typically lower‑cost medications (commonly generics) before covering more expensive brand or specialty agents. Under these rules, a formulary product is covered without prior authorization only when the member's pharmacy history documents the specified comparator or prerequisite medication(s) within the product‑specific lookback window; otherwise a prior authorization is required.
Policy Versions and Updates
Step therapy criteria list updated and published for Independent Health 2026 formularies (document current as of 5/1/2026).
ONGENTYS routing criteria and QUILLICHEW/QUILLIVANT methylphenidate lookback entries referenced with 5/1/2026 date in document body.
Trintellix routing clarified: prescription routes online if generic SSRI documented within previous 90 days; otherwise prior authorization required.
Febuxostat (Uloric) routing clarified: prescription routes online if allopurinol documented within previous 90 days; otherwise prior authorization required.
Xphozah routing clarified: prescription routes online if concurrent phosphate binder use documented within previous 120 days; prescriber may request authorization if not documented.
Sublingual zolpidem routes online if generic zolpidem documented within previous 90 days; otherwise prior authorization required.
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