Independent Health step therapy Prior Auth

Product-specific Coverage and Routing Rules

Product-specific step therapy coverage

Covered when ALL of the following are met for the specific product:

prior-fill requirement example: Member's pharmacy profile documents a specified prior fill or concurrent medication within the product-specific lookback window (e.g., generic alternative filled within 90/180/365 days or concurrent levodopa/carbidopa use).see thresholds per 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.

prior-fill-pass: Patient pharmacy history documents fill of specified comparator/prerequisite medication within the stated lookback window (product-specific).product-specific (30-365 days)

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:

General fill-history rule: Patient's Independent Health prescription history documents the specified prior medication fill within the product-specific look-back windowsee thresholds per product

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

Trintellix 5 mg routing: Prescription is routed online if Independent Health prescription history documents a fill of a generic SSRI (e.g., sertraline, fluoxetine, escitalopram) within the previous 90 days.90 days

If criterion not met, prior authorization required

Febuxostat routing criteria

Febuxostat routing: Prescription is routed online if Independent Health prescription history documents that allopurinol was filled within the previous 90 days.90 days

If criterion not met, prior authorization required

Xphozah routing criteria

Xphozah routing: Prescription is routed online if Independent Health prescription history documents concurrent (within the previous 120 days) use of a phosphate binder.120 days

If not documented, prescriber may request authorization via standard process

Zolpidem sublingual routing criteria

Zolpidem sublingual routing: Prescription is routed online if Independent Health prescription history documents that generic zolpidem was filled within the previous 90 days.90 days

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.