Step therapy criteria and pharmacy prior-authorization gating based on member prescription history
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Defines medications subject to step therapy and the pharmacy prior authorization requirements based on members' prescription history for Independent Health formularies; applies to providers and pharmacies filling prescriptions for affected members.
No material clinical or coverage changes in this revision.
Coverage / Step Therapy Criteria
Initial step therapy conditions by product
Coverage for the listed products is approved when ALL of the following member-specific prior therapy conditions are met for each product as specified:
EUCRISA prior-fill criterion
Covered without prior authorization when the following is met
If not met, prior authorization required
90-day prior-fill criteria
Covered without prior authorization when ANY of the following drug-specific prior fills are present in the member's pharmacy history within 90 days
If not met, prior authorization required
If not met, prior authorization required
If not met, prior authorization required
If not met, prior authorization required
If not met, prior authorization required
If not met, prior authorization required
If not met, prior authorization required
High-potency narcotics prior-fill criterion
Covered without prior authorization when the following is met
If not met, prior authorization required because these medications pose serious risks if started in a narcotic-naïve patient
Online processing / Prior Authorization gating criteria
Covered when the pharmacy profile documents the specific prior fill or concurrent therapy within the time window listed for the product; otherwise prior authorization is required.
If criterion not met prior authorization is required
Step therapy / prior therapy requirements
Covered with criteria when the specified prior therapy is documented in Independent Health prescription history within the stated look-back period; otherwise prior authorization required.
There are no explicit clinical exclusions stated in this portion of the policy excerpt. The coverage criteria instead implement pharmacy-history–based step therapy rules and prior-authorization gating (lookback windows and required comparator fills) rather than listing conditions or diagnoses that would categorically exclude a member from coverage.
The policy explicitly treats the listed high-potency opioid ER and fentanyl transdermal products differently: starting these agents in a narcotic‑naïve patient is discouraged. To avoid prior authorization, the member's Independent Health prescription history must document narcotic medication fills within the prior 120 days; absent that documentation, prior authorization is required.
Within the excerpt provided there are no statements that label any therapy or product as ‘not medically necessary’. Coverage decisions here are framed as conditional — based on documented prior fills or diagnoses in the pharmacy profile — and noncompliance with those conditions routes the claim to standard prior‑authorization review rather than an explicit non‑medical‑necessity determination.
Affected Products and Lookback Windows
| EUCRISA OINTMENT 2 % EXTERNAL | Product affected |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL | Product affected |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL | Product affected |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 40 MG ORAL | Product affected |
| FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL | Product affected |
| glycopyrrolate solution 1 mg/Sml oral | Product affected |
| gabapentin (once-daily) tablet 300 mg oral | Product affected |
| gabapentin (once-daily) tablet 600 mg oral | Product affected |
| HORIZANT TABLET EXTENDED RELEASE 300 MG ORAL | Product affected |
| HORIZANT TABLET EXTENDED RELEASE 600 MG ORAL | Product affected |
| doxercalciferol capsule 0.5 mcg oral | Product affected |
| doxercalciferol capsule 1 mcg oral | Product affected |
| doxercalciferol capsule 2.5 mcg oral | Product affected |
| RAYALDEE CAPSULE EXTENDED RELEASE 30 MCG ORAL | Product affected |
| hydrocortisone valerate ointment 0.2 % external | Product affected |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 12.5 mg oral | Product affected |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 25 mg oral | Product affected |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 37.5 mg oral | Product affected |
| amphet-dextroamphet 3-bead er capsule extended release 24 hour 50 mg oral | Product affected |
| memantine hcl-donepezil hcl capsule extended release 24 hour 14-10 mg oral | Product affected |
| memantine hcl-donepezil hcl capsule extended release 24 hour 21-10 mg oral | Product affected |
| memantine hcl-donepezil hcl capsule extended release 24 hour 28-10 mg oral | Product affected |
| NAMZARIC CAPSULE EXTENDED RELEASE 24 HOUR 7-10 MG ORAL | Product affected |
| fentanyl patch 72 hour 100 mcg/hr transdermal | Product affected |
| fentanyl patch 72 hour 25 mcg/hr transdermal | Product affected |
| fentanyl patch 72 hour 12 mcg/hr transdermal | Product affected |
| fentanyl patch 72 hour 50 mcg/hr transdermal | Product affected |
| fentanyl patch 72 hour 75 mcg/hr transdermal | Product affected |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 100 mg oral | Product affected |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 120 mg oral | Product affected |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 80 mg oral | Product affected |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 60 mg oral | Product affected |
| hydrocodone bitartrate er tablet er 24 hour abusedeterrent 40 mg oral | Product affected |
Prior Authorization Triggers and Pharmacy Documentation
Obtain prior authorization when step criteria aren't met
If the pharmacy profile does not document the required prior-fill or diagnosis within the specified lookback window for a product, the claim will be routed to prior authorization; submit a PA to avoid denial.
- Step-therapy exceptions require PA when prior-fill criteria are not met.
- Lookback windows vary by product (see individual entries).
EUCRISA: PA if no tacrolimus/pimecrolimus/topical corticosteroid in prior 365 days
For EUCRISA ointment, prior authorization is required if the member's Independent Health pharmacy history does not show a tacrolimus, pimecrolimus, or topical corticosteroid fill within the previous 365 days.
Fetzima: PA if no venlafaxine ER fill in prior 90 days
For Fetzima, prior authorization is required if the pharmacy profile does not document a venlafaxine extended‑release capsule filled within the previous 90 days.
Glycopyrrolate: PA if no generic glycopyrrolate tablet fill in prior 90 days
For glycopyrrolate products, prior authorization is required when the pharmacy profile does not document a generic glycopyrrolate tablet fill within the previous 90 days.
Gabapentin / Amphetamine‑dextroamphetamine: PA if no specified comparator fill in prior 90 days
For the listed gabapentin and amphetamine‑dextroamphetamine ER products, prior authorization is required if the pharmacy profile does not document the specified comparator (gabapentin or amphetamine‑dextroamphetamine ER) fill within the previous 90 days.
Doxercalciferol / Rayaldee: PA if no calcitriol fill in prior 90 days
For doxercalciferol and Rayaldee products, prior authorization is required if the pharmacy profile does not document a calcitriol fill within the previous 90 days.
Hydrocortisone valerate: PA if no triamcinolone fill in prior 90 days
For hydrocortisone valerate ointment, prior authorization is required if the pharmacy profile does not document a triamcinolone fill within the previous 90 days.
Namzaric: PA if no donepezil or memantine fill in prior 90 days
For Namzaric (memantine–donepezil ER), prior authorization is required if the pharmacy profile does not document a donepezil or memantine fill within the previous 90 days.
High‑potency opioids: PA if no narcotic fills in prior 120 days
For listed high‑potency opioid ER and patch products, prior authorization is required if the pharmacy profile does not document narcotic medication fills within the previous 120 days.
- Applies to multiple fentanyl patches and ER opioid formulations listed in the policy.
- These agents require documented prior narcotic use because of initiation risk in narcotic‑naïve patients.
High‑potency opioids: PA required when 120‑day narcotic history absent
If the pharmacy profile does not show a narcotic fill in the prior 120 days for the listed high‑potency opioids, prior authorization is required and the prescription may be denied without it.
Ongentys: PA if no entacapone or levodopa‑carbidopa‑entacapone use in prior 180 days
For Ongentys, prior authorization is required if the pharmacy profile does not document concurrent entacapone or levodopa‑carbidopa‑entacapone use within the past 180 days.
Oxcarbazepine ER: PA if no oxcarbazepine fill in prior 90 days
Oxcarbazepine ER requires prior authorization when the pharmacy profile does not document an oxcarbazepine fill within the previous 90 days.
Qelbree: PA if no prior atomoxetine fill documented
For Qelbree, prior authorization is required if the pharmacy profile does not document a prior atomoxetine fill within the timeframe indicated in the policy.
Methylphenidate ER: PA if no generic methylphenidate SR/ER fill in prior 90 days
Quillichew/Quillivant XR (methylphenidate ER) requires prior authorization if the pharmacy profile does not document a generic methylphenidate SR/ER fill within the previous 90 days.
Aliskiren: PA if no prior ACE and ARB fills within 180 days
For aliskiren, prior authorization is required if the pharmacy profile does not document prior ACE inhibitor and ARB fills within the previous 180 days.
Sancuso: PA if no ondansetron fill in prior 180 days
Sancuso patch requires prior authorization when the pharmacy profile does not document an ondansetron fill within the previous 180 days.
Serevent Diskus: PA if no concurrent inhaled corticosteroid or Spiriva use documented
Serevent Diskus requires prior authorization if the pharmacy profile does not document concurrent inhaled corticosteroid or Spiriva use as specified in the policy.
Tazarotene: PA if no tretinoin or adapalene fill in prior 90 days
Tazarotene topical products require prior authorization when the pharmacy profile does not document a tretinoin or adapalene fill within the previous 90 days.
Tramadol ER: PA if no immediate‑release tramadol fill in prior 90 days
Tramadol ER products require prior authorization if the pharmacy profile does not document an immediate‑release tramadol fill within the previous 90 days.
Tramadol ER: PA required when immediate‑release tramadol history absent
Claims for tramadol ER will require prior authorization if the patient's Independent Health prescription history does not document immediate‑release tramadol filled within the previous 90 days.
Trintellix: PA if no generic SSRI fill in prior 90 days
Trintellix requires prior authorization if the pharmacy profile does not document a filled generic SSRI within the previous 90 days.
Febuxostat (Uloric): PA if no allopurinol fill in prior 90 days
Febuxostat (Uloric) requires prior authorization when the pharmacy profile does not document an allopurinol fill within the previous 90 days.
Xphozah: PA if no concurrent phosphate binder use in prior 120 days
A prescription for Xphozah (tenapanor) will require prior authorization if Independent Health prescription history does not document concurrent use of a phosphate binder within the previous 120 days; prescriber may request authorization via standard process when history is absent.
Sublingual zolpidem: PA if no generic zolpidem fill in prior 90 days
Sublingual zolpidem requires prior authorization if the pharmacy profile does not document a generic zolpidem fill within the previous 90 days.
Step therapy enforcement (ST designation and summary)
Medications designated 'ST' on the formulary require trials of specified medications; this policy enforces step‑therapy behavior by using prior‑fill history as the prerequisite for online processing and routes claims to prior authorization when those prior‑fill criteria are not met.
- 'ST' on formulary indicates step therapy requirement.
- Absence of documented prior fills within the product‑specific lookback windows triggers PA.
Prior‑fill history acts as step prerequisite
The policy uses prior Independent Health prescription fills as step requirements: if the required prior fill is not present within the product's lookback window (90, 120, or 365 days as specified), the claim is routed to prior authorization.
Opioid continuation: recent narcotic fill within 120 days required
To avoid PA for high‑potency narcotics, the pharmacy profile must document a narcotic medication fill within the previous 120 days; absence of such documentation triggers prior authorization.
Product‑specific prior‑fill/concurrent‑therapy requirements
Each product in the list requires the pharmacy prescription history to document the specific prior fill or concurrent therapy and timeframe referenced in the policy (e.g., entacapone or levodopa‑carbidopa‑entacapone for Ongentys; oxcarbazepine within 90 days; immediate‑release tramadol within 90 days for tramadol ER).
Tramadol ER: online processing allowed only with immediate‑release tramadol documented
Online processing for tramadol ER is allowed only if Independent Health prescription history documents immediate‑release tramadol filled within the previous 90 days; otherwise a prior authorization is required.
Trintellix: online processing requires prior generic SSRI fill
For Trintellix, online processing is allowed only when the Independent Health prescription history documents a generic SSRI filled within the previous 90 days; otherwise prior authorization is required.
Febuxostat (Uloric): online processing requires prior allopurinol fill
For febuxostat (Uloric) 40 mg and 80 mg, online processing is allowed only if the prescription history documents an allopurinol fill within the previous 90 days; otherwise prior authorization is required.
Xphozah: online processing requires documented phosphate binder use
For Xphozah (tenapanor), online processing is allowed only if Independent Health prescription history documents concurrent phosphate binder use within the previous 120 days; otherwise prescriber must request authorization.
Sublingual zolpidem: online processing requires prior generic zolpidem fill
Sublingual zolpidem will process online only when Independent Health prescription history documents a generic zolpidem fill within the previous 90 days; absent that documentation, prior authorization is required.
Document prior fills in Independent Health prescription history
The pharmacy must document prior fills in the member's Independent Health prescription history to meet step therapy criteria; contact Member Services for questions about documentation or exceptions.
- Document comparator drug name and fill date in Independent Health prescription history.
- If history is incomplete, prescriber may submit PA via standard authorization process.
Required pharmacy fill history for comparator medications
Pharmacies must ensure the member's Independent Health prescription history documents the specified comparator medication(s) within the defined lookback windows (e.g., 90, 120, or 365 days) to allow online processing and avoid prior authorization.
Narcotic fill documentation for high‑potency opioids (120‑day rule)
For listed high‑potency narcotics, the pharmacy profile must document a prior narcotic fill within 120 days (per the policy's narcotic‑continuation requirement) to avoid prior authorization.
Pharmacy history must list the exact comparator drug(s) and timeframe
Pharmacy prescription history must document the specific drug(s) and timeframe referenced for each product (e.g., entacapone or levodopa‑carbidopa‑entacapone for Ongentys; oxcarbazepine within 90 days; atomoxetine for Qelbree) to permit online processing.
Online processing requires documented recent fills in IH prescription history
To process claims online, the Independent Health prescription history must show the recent fills within the product‑specific lookback windows (90 or 120 days as noted); otherwise the prescriber must request prior authorization through the standard process.
Aczone: PA if no generic dapsone 5% fill in prior 90 days
For Aczone (dapsone 7.5% gel), prior authorization is required when the pharmacy profile does not document a generic 5% dapsone fill within the previous 90 days.
Bepotastine ophthalmic: PA if no Zaditor/Alaway OTC fill in prior 90 days
For bepotastine ophthalmic solution, prior authorization is required when the pharmacy profile does not document a Zaditor or Alaway OTC fill within the previous 90 days.
GLP‑1 agents: PA if no type 2 diabetes diagnosis or prior oral antidiabetic (excl. metformin) within 130 days
GLP‑1 antidiabetic agents require evidence of type 2 diabetes or a trial of any oral antidiabetic (excluding metformin) within the past 130 days; prior authorization is required if this is not documented in the pharmacy profile.
Antiemetics: PA if no ondansetron fill in prior 180 days
Certain antiemetics require prior authorization when the pharmacy profile does not document a generic ondansetron fill within the previous 180 days.
Belsomra: PA if no generic zolpidem fill in prior 365 days
Belsomra products require prior authorization if the pharmacy profile does not document a generic zolpidem fill within the previous 365 days.
Binosto: PA if no alendronate fill in prior 90 days
Binosto requires prior authorization when the pharmacy profile does not document alendronate filled within the previous 90 days.
Bromfenac ophthalmic: PA if no generic bromfenac 0.09% fill in prior 90 days
Bromfenac ophthalmic products require prior authorization if the pharmacy profile does not document generic bromfenac ophthalmic solution 0.09% once daily filled within the previous 90 days.
Entacapone/Ongentys: PA if no concurrent levodopa/carbidopa documented
Entacapone/Ongentys require prior authorization when the pharmacy profile does not document concurrent use of a levodopa/carbidopa product.
NSAID comparator required for diclofenac potassium (migraine) packets
Diclofenac potassium (migraine) packets require prior authorization if the pharmacy profile does not document a generic NSAID fill.
EUCRISA: prior topical therapy required (restated)
This EUCRISA instruction restates that PA is required when tacrolimus, pimecrolimus, or a topical corticosteroid fill within the prior 365 days is not documented in the pharmacy profile.
EUCRISA prior‑fill requirement (duplicate)
This is a duplicate EUCRISA prior‑fill instruction: if tacrolimus, pimecrolimus, or a topical corticosteroid was not filled within the prior 365 days, prior authorization is required and the claim may be denied without it.
90‑day prior‑fill enforcement summary
Multiple products in the policy use 90‑day lookbacks; if the specified comparator fill is not documented within 90 days, prior authorization is required and the claim may be denied without it.
High‑potency narcotics: 120‑day enforcement summary
High‑potency narcotics are subject to a 120‑day prior‑fill enforcement rule: absence of documented narcotic fills within 120 days triggers prior authorization.
High‑potency opioid PA trigger (restated)
Restatement: claims for the listed high‑potency opioids require documented narcotic medication filled within the previous 120 days; otherwise prior authorization is required.
Ongentys PA trigger (restated)
Restatement: Ongentys requires documentation of entacapone or levodopa‑carbidopa‑entacapone use within 180 days; absence requires prior authorization.
Oxcarbazepine ER PA trigger (restated)
Restatement: Oxcarbazepine ER requires a prior oxcarbazepine fill within 90 days to process online; otherwise prior authorization is required.
Qelbree PA trigger (restated)
Restatement: Qelbree requires prior atomoxetine fill to avoid prior authorization.
Methylphenidate ER PA trigger (restated)
Restatement: Quillichew/Quillivant XR requires a generic methylphenidate SR/ER fill within 90 days to process online; otherwise prior authorization is required.
Aliskiren PA trigger (restated)
Restatement: Aliskiren requires prior ACE and ARB fills within 180 days to process online; otherwise prior authorization is required.
Sancuso PA trigger (restated)
Restatement: Sancuso requires ondansetron fill within 180 days to process online; otherwise prior authorization is required.
Serevent Diskus PA trigger (restated)
Restatement: Serevent Diskus requires documented concurrent inhaled corticosteroid or Spiriva use to process online; otherwise prior authorization is required.
Tazarotene PA trigger (restated)
Restatement: Tazarotene topical requires tretinoin or adapalene fill within 90 days to process online; otherwise prior authorization is required.
Tramadol ER PA trigger (restated)
Restatement: Tramadol ER requires an immediate‑release tramadol fill within 90 days to process online; otherwise prior authorization is required.
Tramadol ER prior authorization (duplicate)
Duplicate: Tramadol ER prior authorization instruction (claims require PA if immediate‑release tramadol not documented in prior 90 days).
Trintellix PA trigger (restated)
Restatement: Trintellix requires documentation of a generic SSRI filled within the previous 90 days to process online; otherwise prior authorization is required.
Febuxostat PA trigger (restated)
Restatement: Febuxostat requires prior allopurinol fill within 90 days to process online; otherwise prior authorization is required.
Xphozah PA trigger (restated)
Restatement: A prescription for Xphozah will require prior authorization if concurrent phosphate binder use within the previous 120 days is not documented in the prescription history.
Sublingual zolpidem PA trigger (restated)
Restatement: Sublingual zolpidem requires a generic zolpidem fill within the previous 90 days for online processing; otherwise prior authorization is required.
Policy Background
Step therapy is a utilization management approach that requires trials of specified, typically lower‑cost or first‑line medications before coverage of alternatives. This policy operationalizes step therapy by using the member's Independent Health prescription history as the trigger: online claim processing is allowed when the pharmacy profile documents the required comparator fill or diagnosis within the stated lookback window (for example, 90 days for many agents, 120 days for listed high‑potency opioids, and 365 days for certain topical comparators). If the required prior fill or concurrent therapy is not documented in the pharmacy profile, the prescription is routed to prior authorization.
Key Definitions
Initial Therapy Rules
Initial therapy for GLP-1 antidiabetics
GLP-1 agents require evidence of type 2 diabetes diagnosis or prior oral antidiabetic therapy (excluding metformin).
Initial therapy rules
Initial dispensing rules based on prior therapy documentation in Independent Health prescription history.
Step Therapy Lookup Table
| Requirement | Look-back window | If not documented |
|---|---|---|
| Document prior fills or diagnoses in the member's Independent Health prescription history for the specified comparator medication or condition | ||
| 90, 130, 180, or 365 days (varies by product) | ||
| Claim routed to prior authorization; prior authorization required |
| Drug / Comparator | Required prior fill in pharmacy profile | Look-back window |
|---|---|---|
| Fetzima | ||
| Venlafaxine extended‑release capsule fill documented in Independent Health pharmacy history | ||
| 90 days | ||
| Glycopyrrolate products | ||
| Generic glycopyrrolate tablet fill documented in pharmacy history | ||
| 90 days | ||
| Gabapentin / Horizant | ||
| Gabapentin fill documented in pharmacy history | ||
| 90 days | ||
| Doxercalciferol / Rayaldee | ||
| Calcitriol fill documented in pharmacy history | ||
| 90 days | ||
| Hydrocortisone valerate ointment | ||
| Triamcinolone fill documented in pharmacy history | ||
| 90 days | ||
| Amphetamine–dextroamphetamine ER | ||
| Amphetamine–dextroamphetamine ER fill documented in pharmacy history | ||
| 90 days | ||
| Namzaric | ||
| Donepezil or memantine fill documented in pharmacy history | ||
| 90 days |
| Requirement | Look-back window | If not documented |
|---|---|---|
| Pharmacy profile documents prior narcotic medication fills for the member (continuation/step requirement for listed high‑potency opioids) | ||
| 120 days | ||
| Prior authorization required and claim may be denied without it |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Ongentys (opicapone) | ||
| Concurrent use of entacapone or levodopa–carbidopa–entacapone documented in Independent Health pharmacy history | ||
| 180 days; prior authorization required if not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Oxcarbazepine ER | ||
| Oxcarbazepine fill documented in Independent Health pharmacy history | ||
| 90 days; prior authorization required if not documented |
| Product | Required documented therapy | Action if absent |
|---|---|---|
| Qelbree (viloxazine ER) | ||
| Prior atomoxetine (Strattera) fill documented in Independent Health pharmacy history | ||
| Prior authorization required if atomoxetine fill not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Quillichew / Quillivant XR (methylphenidate ER formulations) | ||
| Generic methylphenidate slow‑release or extended‑release product fill documented in pharmacy history | ||
| 90 days; prior authorization required if not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Aliskiren fumarate | ||
| Prior fills of an ACE inhibitor and an ARB documented in Independent Health pharmacy history | ||
| 180 days; prior authorization required if both are not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Sancuso (ondansetron patch) | ||
| Ondansetron fill documented in Independent Health pharmacy history | ||
| 180 days; prior authorization required if not documented |
| Product | Required documented therapy | If not documented |
|---|---|---|
| Serevent Diskus (salmeterol) | ||
| Concurrent use of an inhaled corticosteroid or Spiriva documented in pharmacy history | ||
| Prior authorization required if concurrent therapy not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Tazarotene topical (cream/gel) | ||
| Tretinoin or adapalene fill documented in Independent Health pharmacy history | ||
| 90 days; prior authorization required if not documented |
| Product | Required documented therapy | Look-back window / Action if absent |
|---|---|---|
| Tramadol ER formulations | ||
| Immediate‑release tramadol fill documented in Independent Health pharmacy history | ||
| 90 days; prior authorization required if not documented |
| Consolidated requirement | Examples (products) | Look-back / Action if absent |
|---|---|---|
| Online processing allowed only when the member's Independent Health prescription history documents the specific prior comparator therapy or concurrent medication listed for the product; otherwise prescriber must obtain prior authorization | ||
| Examples: prior generic SSRI for Trintellix; allopurinol for febuxostat (Uloric); concurrent phosphate binder for Xphozah; generic zolpidem for sublingual zolpidem | ||
| Generally 90 days (most comparators); 120 days for high‑potency opioids or tenapanor concurrent binder; 180 or 365 days for select products as specified — prior authorization required if not documented |
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