CurrentIndependent HealthPolicy N/A

Independent Health 2025 FEHB Drug Formulary (Introductory / Part 1)

Introductory sections of Independent Health's 2025 FEHB drug formulary covering formulary structure (5 tiers), program rules (prior authorization, step therapy, quantity limits, specialty and limited distribution drugs), definitions/keys for formulary flags, compounded medication policy summary, diabetic supplies and insulin cost-share rules, exclusions (cosmetic, non-FDA/NDC, medical foods), OTC COVID test coverage, and partial drug list entries (fragment of Tier/notes for multiple drugs). Applies to FEHB plans offered by Independent Health.

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2025 FEHB Drug Formulary (Introductory / Part 1)

Policy CodePolicy N/A

Change TypeClarified (Post‑Exposure Prophylaxis update noted)

Effective Date

Next Review Date

Key ActionProviders must submit prior authorization requests or medical exception forms to Independent Health's Prior Authorization Department for PA‑flagged drugs or non‑formulary coverage; approval is required for coverage.

SourceLink

POLICY UPDATE CHANGES

Revised August 2025 noted in document for Post-Exposure Prophylaxis coverage statement.

5Formulary tiers

MultipleUtilization flags (PA/ST/QL/SP/LDD)

8OTC COVID tests per 30 days

100/300Diabetic test strip limits (non‑insulin/insulin)

severalSpecialty/oncology restricted agents

Coverage Summary

This section is the introductory operational rules for Independent Health's FEHB 2025 drug formulary. It explains the formulary structure and programs that govern coverage and how members and providers must follow utilization management and program rules when obtaining medications.

The formulary uses a 5-tier structure to assign member cost-sharing and place drugs by preferred, non-preferred and specialty status; tiers are numbered 1–5 with Tier 1 the lowest cost-sharing and Tiers 3 and 5 among the highest.

Utilization management programs applied across the formulary include Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL); entries annotated SP denote specialty pharmacy routing and LDD denotes limited distribution drug handling.

Specialty and limited-distribution agents are routed through designated specialty channels (e.g., Reliance Rx) and often require PA or site-of-care handling; many high-cost oncology and specialty agents are placed in higher tiers with PA/SP/LDD flags.

Compounded prescriptions must be prepared by a participating pharmacy, contain at least one prescription component, and are covered at Tier 2; compounds costing ≤ $200 do not require prior authorization but compounds costing > $200 require PA.

Diabetic supplies and insulin rules: insulin has a maximum cost-share per 30-day supply; preferred glucose meters and supplies (FreeStyle) are available without PA and Abbott will provide one meter per member at no member cost-share; continuous glucose monitors follow specified sensor and transmitter limits.

Over-the-counter COVID tests are covered only if FDA-approved (including EUA), self-administered and read by the member without a doctor’s order, and limited to up to 8 OTC tests per member per 30 days (equivalent to four two-test kits).

General Formulary Coverage Conditions

Formulary coverage and utilization program rules:

Formulary listing and medical exceptions: Drug is listed on the Independent Health formulary (Tier 1-5) or may be covered via a medical exception submitted by the prescriber and approved by Independent Health
Non-formulary drugs may be covered at Tier 3 or Tier 5 if a medical exception is approved.
Prior Authorization (PA): Medications requiring Prior Authorization are noted 'PA' on the formulary; providers must submit a PA request for coverage and receive approval
Medications that require prior authorization are listed with a 'PA' in the formulary.
Step Therapy (ST): Medications marked 'ST' require trial(s) of specified preferred medications before the non-preferred therapy is covered
Medications that require step therapy are listed with a 'ST' in the formulary.

Compounded Medications

Compounded Medications Coverage

Compounded prescription coverage rules and prior authorization threshold:

Participating pharmacy and prescription component: Compound must be prepared by a participating pharmacy and contain at least one prescription component
Cost threshold and prior authorization: Compounds costing $200 or less do not require prior authorization if other requirements are met; compounds costing more than $200 require prior authorization and the dispensing pharmacy must submit for prior approval> $200 requires prior authorization
Compounds which cost under $200 do NOT require prior authorization if all other requirements are met; compounds which cost more than $200 will require prior authorization.
Cost-sharing and tier:

Diabetic Supplies and Insulin

Diabetic Supplies and Insulin Coverage

Coverage, cost-share and quantity limits for insulin and diabetic supplies:

Insulin cost-share rules: Insulin has a maximum member cost-share per 30-day supply; if obtained at a pharmacy member pays the lesser of diabetic or pharmacy cost-share; if obtained at a medical supply provider member pays the diabetic cost-share
Insulin has a maximum cost-share per 30-day supply; pharmacy: pay lesser of diabetic or pharmacy cost-share; medical supply provider: pay diabetic cost-share.
Preferred supplies and PA: FreeStyle glucose meters, lancets, test strips and supplies are preferred and do not require prior authorization; Abbott will provide one FreeStyle glucose meter per member at no member cost-share with ID and offer code
FreeStyle glucose meters, lancets, test strips, and supplies are preferred and do not require prior authorization; Abbott will provide a glucose meter with no member cost-sharing (one per member).

Over-the-Counter COVID Tests

OTC COVID Tests

Coverage rules for over-the-counter COVID-19 tests provided without a doctor's order:

FDA approval / EUA: Only OTC COVID tests approved by the FDA (including EUA-authorized tests) are covered
Only OTC COVID tests approved by the FDA (including the EUA process) are covered.
Self-administered and member-read: Covered tests must be self-administered and read by the member without a doctor's order or clinical assessment and are not sent to a lab for processing
These tests are administered and read by the member without a doctor's order or clinical assessment and are not sent to a lab for processing.
Dispensing limit per 30 days: Each member may obtain up to eight (8) OTC tests in a 30-day period (typically four two-test kits) without a doctor's order

Exclusions & Special Exclusion Rules

Exclusions and Special Exclusion Rules

Items and medication categories excluded or specially limited under the formulary:

Cosmetic medications excluded: Medications used for cosmetic purposes are excluded from coverage
Medications used for cosmetic purposes are excluded from coverage.
Medical devices excluded except listed diabetic supplies and inhaler spacers: Medical devices are excluded except for previously listed diabetic supplies and spacers for inhalers (which may or may not require a prescription)
Only previously listed diabetic supplies and inhaler spacers are covered; all other devices are excluded.
Medical foods and prenatal vitamins: Medical foods are excluded except when used to treat inborn errors of metabolism (e.g., PKU); prenatal vitamins classified as medical foods are not covered and multivitamins are not included on the formulary

Utilization Management & Provider Requirements

Prior Authorization

Prior Authorization Required

Submit prior authorization requests for medications and medical exceptions as indicated in the formulary. Prior authorization (PA) is required for many Tier 5 and select Tier 3/4 products, compounded prescriptions costing > $200, and specified products or durations noted with a 'PA' formulary flag. Providers must submit PA/medical exception forms and clinical rationale to Independent Health's Prior Authorization Department; fax instructions are available on the formulary. Ensure PA is obtained before dispensing to avoid denial of coverage.

PA required for many Tier 5 and select Tier 3/4 drugs (see formulary 'PA' flags)
Compounded prescriptions > $200 require prior authorization; participating pharmacy must submit prior approval
Medical exception requests (non-formulary or step overrides) require completed medical exception form and clinical rationale
PA applies to specified products/durations noted in formulary entries

Applicable Codes & Formulary Flags

Tier 1 entriesmixedCovered

armodafinil / modafinil	n/a - wakefulness agents (multiple formulations)
acebutolol hcl oral capsule	beta blocker - Tier 1 sample
amandadine hcl oral capsule/solution/tablet	antiviral/anti-parkinson agent (multiple forms)
carbidopa oral tablet	parkinson agent - Tier 1 sample
entacapone oral tablet	COMT inhibitor (entacapone)
pramipexole dihydrochloride oral (multiple forms)	dopaminergic antiparkinson agent
rasagiline mesylate oral tablet	MAO-B inhibitor
quetiapine fumarate (various)	antipsychotic - multiple formulations
risperidone oral solution/tablet/dispersible	antipsychotic - multiple formulations
ziprasidone hcl oral capsule	antipsychotic

1–10 of 13

1/2

Tier 3 entriesmixedExperimental

CONTRAVE (bupropion/naltrexone) ORAL TABLET ER 12 HOUR	weight management agent - ER formulation
INBRIJA INHALATION CAPSULE	levodopa inhalation for OFF episodes - single entry
carbidopa-levodopa-entacapone	combination parkinson agent (Stalevo)
prochlorperazine rectal/suppository	antiemetic/antipsychotic rectal formulation
thioridazine hcl oral tablet	typical antipsychotic - older agent
thiothixene oral capsule	typical antipsychotic
trifluoperazine hcl oral tablet	typical antipsychotic
abacavir sulfate oral solution / abacavir-lamivudine	antiretroviral formulations
oseltamivir phosphate oral capsule (reconstituted mg/5ml)	influenza antiviral - reconstituted suspension mapping
amoxicillin oral suspension reconstituted	antibiotic - reconstituted suspension example

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Tier 4 entriesmixed

MEKTOVI ORAL TABLET	mekinist/mektovi oncology mapping note (temozolomide oral capsule mapping)
XPOVIO (40 MG) ORAL TABLET THERAPY PACK	multiple regimen oncology oral pack (xpoVIO)
XPOVIO (various regimens)	multiple oncology entries - specialty handling
Many oncology and specialty agents	TAFINLAR, TAGRISSO mapping, MEKINIST, MEKTOVI, NINLARO, NUBEQA, ODOMZO, OJEMDA, OJJAARA, ONUREG, NERLYNX, VENCLEXTA, etc.
DARUNAVIR ORAL TABLET	antiretroviral - specialty tier
EPCLUSA ORAL PACKET / ORAL TABLET	HCV agent - sofosbuvir-velpatasvir
VOSEVI ORAL TABLET	HCV salvage regimen
SOFOSBUVIR-VELPATASVIR ORAL TABLET	HCV pan-genotypic regimen
TRIUMEQ ORAL TABLET	dolutegravir/abacavir/lamivudine - antiretroviral
TYBOST ORAL TABLET	cobicistat boosting agent

1–10 of 13

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Tier 5 entries (specialty/high tier)mixed

MEKTOVI ORAL TABLET (temozolomide oral capsule mapping)	oncology agent mapping entry
mesna oral tablet	uroprotectant used with ifosfamide/cyclophosphamide
aripiprazole oral solution	antipsychotic solution formulation
INBRIJA INHALATION CAPSULE (one entry)	inhaled levodopa - specialty
pramipexole dihydrochloride er	extended-release antiparkinson formulation
PROPRANOLOL HCL ORAL SOLUTION	one entry - solution formulation
HEMANGEOL ORAL SOLUTION	infantile hemangioma topical/oral solution
SOTYLIZE ORAL SOLUTION	oral solution formulation
bosentan oral tablet soluble	pulmonary hypertension agent - soluble tablet
TAFINLAR	oncology - specialty

1–10 of 17

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Definitions / Keys

This document uses several key abbreviations and flags on the formulary entries. Definitions below consolidate duplicate terms and commonly used annotations found in this part.

PA = Prior Authorization Required — medications listed with a "PA" require a prior authorization request submitted by the provider and approval by Independent Health.

ST = Step Therapy — medications listed with an "ST" require trial(s) of specified preferred medication(s) first.

QL = Quantity Limits Apply — indicates a quantity limit per 30 or 90 days as shown on the formulary.

SP = Specialty Pharmacy — specialty medications listed with "SP" are dispensed through designated specialty channels (e.g., Reliance Rx).

LDD = Limited Distribution Drug — indicates manufacturer-limited distribution requiring specific dispensing channels.

MM = Maintenance Medications — eligible for up to a 90-day supply where indicated.

ACA = Affordable Care Act preventive services — medications listed with "ACA" have no member cost-sharing when ACA preventive rules apply.

PV = Preventive (no member cost-sharing for qualifying chronic conditions) — where applicable per member contract.

AL = Age Limit / Age Restriction — medication use may be restricted by age per FDA labeling or plan rules.

DF = Dental Formulary — medications listed with "DF" are covered only when prescribed by a dental provider.

Background & Operational Notes

This part is Independent Health's FEHB 2025 formulary Part which provides introductory operational rules, flags, and a partial listing/index of drug-tier-note entries. It is a fragment of the full formulary and should be used with the complete formulary and member contract for coverage determinations.

The content here is a partial drug-tier-note fragment and index: many alphabetical drug mappings and tier/note annotations are listed as examples or mapped entries; some lines are placeholders or incomplete mappings and do not constitute full coverage criteria.

Specialty distribution: many oncology and specialty agents are annotated with SP and/or LDD, indicating they are dispensed through designated specialty pharmacies or limited distribution channels and typically require prior authorization and program-specific handling.

Compounding summary: compounded prescriptions must be prepared by participating pharmacies, contain at least one prescription component, and are dispensed at Tier 2 when covered; compounds costing > $200 require prior authorization while those costing ≤ $200 do not (if other requirements are met).

This part includes an index and many entry fragments and should be interpreted as an operational segment — clinical criteria, PA forms, and step-therapy pathways are referenced but maintained in full in other plan documents and the Notice of Change when updates occur.

Member Services is available for questions and to provide language assistance and disability communication aids at no cost. Call Member Services at 1-800-501-3439 (local: (716) 631-8701 where listed); TTY users call 711.

Independent Health provides free interpreters and translated materials; members may request qualified sign language interpreters, written materials in alternate formats (large print, audio, electronic), and other language services by contacting Member Services.

Frequently Asked Questions

Q: What happens if a drug is removed from the formulary mid-year?

A: If you are impacted by a formulary change, that change will not affect you until your plan renews the following year; changes are communicated on the website and in a 'Notice of Change.'

Q: How do I get a non-formulary drug covered?

A: Your doctor can request a medical exception by completing a medical exception form and faxing it to Independent Health's Prior Authorization Department; if approved, the drug will be covered at Tier 3 or Tier 5 cost-sharing.

Revision History

August 2025coverage update (clarified)Latest

Medications for HIV post-exposure prophylaxis are covered when a diagnosis is documented. (Detail note: Revised August 2025; change type=clarified; is_material=false)

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2025 FEHB Drug Formulary (Introductory / Part 1)

Policy CodePolicy N/A

Change TypeClarified (Post‑Exposure Prophylaxis update noted)

Effective Date

Next Review Date

SourceLink

On This Page

Quantity Limits (QL): When a 'QL' is shown, quantity limitations apply (e.g., per 30 or 90 days) and formulary QL takes precedence over pre-packaged item limits

Medications with quantity limitations are listed with a 'QL' in the formulary; QL may be per 30 or 90 days.

Specialty (SP) and Limited Distribution (LDD): Specialty medications (SP) and limited distribution drugs (LDD) may be restricted to designated specialty pharmacies (e.g., Reliance Rx) or limited distribution channels; these are listed with 'SP' or 'LDD'

Specialty medications are listed with a 'SP' and limited distribution with 'LDD' on the formulary; Reliance Rx contact provided.

When covered, compounded prescriptions are available at a Tier 2 member cost-sharing

Excluded items: Bulk products and powders are excluded from coverage

Bulk products and powders are excluded from coverage.

Compounding / Prior Authorization Thresholds

Compound cost prior authorization threshold> $200 requires prior authorization

Covered compound cost-sharing tierWhen covered, compounded prescriptions are available at Tier 2 member cost-sharing

Compounding PA exceptionCompounds costing under $200 do NOT require prior authorization if other requirements are met

Notes / exclusionsBulk products and powders are excluded from coverage

Operational noteDispensing pharmacy must submit for prior approval for compounds; compounds > $200 require PA

Needles, syringes and alcohol swabs:

BD needles and syringes (typical insulin sizes) are preferred and covered; other sizes may require prior authorization; alcohol swabs are covered

BD needles and syringes are preferred; other sizes require prior authorization; alcohol swabs to prep diabetic medicines are covered.

Test strip quantity limits: Diabetic test strips limited to maximum of 100 per 30 days for non-insulin dependent diabetics or 300 per 30 days for insulin dependent diabetics100 per 30 days (non-insulin); 300 per 30 days (insulin)

Diabetic test strips are limited to a maximum of 100 per 30 days for non-insulin dependent diabetics and 300 per 30 days for insulin dependent diabetics.

CGM allowances: Continuous glucose monitors: FreeStyle Libre series and Dexcom G6/G7 available at retail pharmacies without prior authorization for members using insulin multiple times daily; FreeStyle Libre: up to 2 sensors/28-day or 6 sensors/84-day and one receiver per plan year; Dexcom G6/G7: up to 3 sensors/30-day or 9 sensors/90-day, one wireless transmitter every 90 days (G7 built-in) and one receiver per plan yearFreeStyle Libre: 2 per 28 days or 6 per 84 days; Dexcom: 3 per 30 days or 9 per 90 days; transmitter every 90 days

FreeStyle Libre and Dexcom sensor and transmitter limits specified.

Diabetic Supplies — Quantity Limits

Diabetic test strips - non-insulin dependent<= 100 per 30 days

Diabetic test strips - insulin dependent<= 300 per 30 days

FreeStyle Libre sensorsUp to 2 sensors per 28-day supply or 6 per 84-day supply; one receiver per plan year

Dexcom G6/G7 sensorsUp to 3 sensors per 30-day supply or 9 per 90-day supply; one wireless transmitter every 90 days (G7 includes built-in transmitter); one receiver per plan year

Procurement noteFreeStyle glucose meters and supplies preferred; Abbott provides one glucose meter per member at no member cost-share (call Abbott with member ID and offer code)

Up to 8 tests per member per 30 days

Each member may get up to eight (8) OTC tests in a 30-day period; most kits have two tests, so four two-test kits per 30 days.

OTC COVID-19 Test Limit

OTC COVID test allowanceUp to 8 tests per member per 30 days (equivalent to 4 two-test kits)

Test typeOnly FDA-approved OTC COVID tests (including EUA) are covered

Medical foods other than those to treat inborn errors of metabolism are excluded; prenatal vitamins classified as medical foods are not covered; multivitamins are not included.

Non-FDA / no NDC items excluded: Medications not recognized by the FDA without an NDC and prescription medications not approved by the FDA are excluded from coverage

Medications not recognized by the FDA without a National Drug Code (NDC) are excluded; prescription medications not approved by the FDA are excluded.

DESI drugs excluded: Drugs found less than effective by the FDA's Drug Efficacy Study Implementation (DESI) are not covered

Drugs found less than effective by FDA DESI are not covered.

Step Therapy

Step Therapy Requirements

Step therapy (ST) requirements apply where noted with an 'ST' flag. Providers should review step therapy prerequisites and document trial of required first-line agents or clinical reasons for exception. Examples include ST prerequisites for certain brand agents where an equally effective generic or alternative must be tried first.

Follow formulary 'ST' flags — document prior trials of required agents
When requesting a medical exception to step therapy, include treatment history and rationale
Step therapy applies to selected Tier 3/4 agents as indicated

Billing Rule

Quantity Limits & Limited Dispensing

Observe quantity limits (QL) and limited dispensing (LDD) rules shown in the formulary. Pharmacies and prescribers must adhere to per‑30 or per‑90 day thresholds, and package-size/prepackaged limits are superseded by QL where applicable. OTC COVID test dispensing is limited to 8 tests per 30 days.

Medications with 'QL' are limited to the stated quantity per 30- or 90-day period
Pre-packaged items: one package allowed per fill unless a formulary QL overrides
OTC COVID tests: limit dispensing to 8 tests per 30 days (pharmacy-level enforcement)
Diabetic test strips: 100/30 days (non-insulin) and 300/30 days (insulin-dependent)

Documentation Required

Specialty Pharmacy, Limited Distribution & Site-of-Care

Specialty medications may require specialty pharmacy (SP) fulfillment, limited distribution (LDD), or site-of-care programs. Reliance Rx Specialty Pharmacy is the designated specialty vendor for many SP products; some LDD products are only available through manufacturer‑designated pharmacies. When specialty channel or limited distribution is required, failure to use the correct channel may result in denial. Confirm SP/LDD routing and coordinate with Reliance Rx (1-800-809-4763) or manufacturer for limited distribution items.

Specialty (SP) products listed on the formulary must be filled at designated specialty pharmacies (e.g., Reliance Rx) when indicated
Limited distribution drugs (LDD) must be obtained through manufacturer-designated pharmacies
Specialty channel required = potential denial risk if filled retail incorrectly
Site-of-care or program-specific requirements may apply (e.g., oncology, infusion)

Prior Authorization

Compounded Prescriptions — Prior Authorization

Compounded prescriptions that exceed $200 require prior authorization. Participating dispensing pharmacies must submit the prior approval request; compounds under $200 do not require PA if all other requirements are met. Bulk products and powders remain excluded from coverage.

Compounds > $200: pharmacy submits prior approval to Independent Health
Compounds < $200: no PA required if other criteria met
Coverage follows the Compounding Medication Products Policy; bulk products and powders excluded

Billing Rule

OTC COVID Test Limits

Pharmacies must limit covered OTC COVID test dispensing to 8 tests per member per 30 days. Enforce quantity rules at point of sale and document dispensing per formulary guidance.

OTC COVID test dispensing limit = 8 tests per 30 days
Pharmacy must track member dispensing to enforce limit

Documentation Required

Medical Exception Submissions and Documentation

For medical exceptions and PA documentation, providers must submit a completed medical exception form with a clear medical necessity rationale and relevant clinical records. Fax the form to Independent Health's Prior Authorization Department per the formulary instructions. Include specialty prescriber attestation where required (e.g., specialist‑restricted agents).

Fax medical exception form to Independent Health Prior Authorization Department with clinical rationale
Attach prior treatment history, diagnostic data, and specialist attestation when applicable
Document reasons for step therapy or formulary override requests

Denial Risk

Denial Risk — Channel, Coding & Mapping Ambiguity

Be alert for denial risks due to specialty channel requirements, limited distribution, coding ambiguity, or missing tier/notes in formulary entries. Ensure correct NDC/CPT/HCPCS mapping and verify coverage codes when billing. Ambiguous or blank tier/notes entries increase risk of claim denial — confirm status with Independent Health prior to dispensing.

Specialty channel required or LDD = increased denial risk if routed incorrectly
Confirm correct NDC/CPT/HCPCS mapping for formulary line items (avoid miscoding)
Entries with blank tier/notes require verification before filling to prevent denial

Specialty Prescriber Restrictions & Attestation

OTC = Over-the-Counter — OTC products covered require a valid prescription for coverage.

SUD = Substance Use Disorder designation — indicates SUD program/edits apply.

Note: The plan may use additional internal annotations (e.g., PV, MM, AL, DF) with plan-specific operational meaning and the full criteria or clinical guidelines for PA/ST are maintained elsewhere in the formulary program materials.

Members may file a grievance with Independent Health's Member Services Department (511 Farber Lakes Drive, Buffalo, NY 14221; phone 1-800-501-3439; fax (716) 635-3504; email memberservice@servicing.independenthealth.com) or with HHS OCR via the OCR Complaint Portal as described in the nondiscrimination statement.