CurrentIndependent HealthPolicy N/A

Child Health Plus Drug Formulary — Prescription Drug Coverage Criteria

Governs the prescription drug formulary for Independent Health's New York State Sponsored Child Health Plus plan, describing coverage, restrictions, and pharmacy requirements for members and providers.

Policy Summary

PayerIndependent Health

PolicyChild Health Plus Drug Formulary — Prescription Drug Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for medicines listed with 'PA' to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA, ST, QL, AL, DF, LDDFormulary flags

FreeStyle preferredPreferred CGM

Dexcom requires PADexcom status

Test strips limitsTest strip limits

4/30 daysOpioid fill limit

state-level

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Coverage rules and exclusions

Formulary coverage and exclusions

Covered when consistent with the member's benefit and state/federal rules.

Formulary applicability: Drug is covered when listed on the Child Health Plus formulary and associated with the member's benefit; members should check their summary of benefits to confirm coverage.

See chunk 0

Prior authorization: Drugs listed with 'PA' require prior authorization; medicines listed as covered without restriction may still require prior authorization or may be denied if used for non–FDA‑approved indications or in conjunction with non‑covered procedures per member contract.

See chunks 1 and 12

Exclusions (examples): Appetite suppressants/weight‑loss medications, medications used for cosmetic purposes, most medical foods (except to treat inborn errors of metabolism such as PKU), prenatal vitamins classified as medical foods, medications for sexual/erectile dysfunction, fertility treatments, growth hormones for short stature, prescription medicines not recognized by the FDA without an NDC, FDA‑unapproved medicines, and drugs found to be less than effective by the FDA DESI process are excluded from coverage.

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Compounded prescriptions

Covered when ALL of the following are met:

Participating pharmacy: The compound must be prepared by a participating pharmacy and contain at least one prescription component.

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Cost threshold — compounds below $200: Compounded prescriptions with total cost under $200 do not require prior authorization provided all other requirements are met.cost < $200

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Cost threshold — compounds $200 or greater: Compounded prescriptions with total cost of $200 or more require prior authorization before coverage is provided.cost >= $200

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Diabetic supplies coverage

Covered when ALL of the following are met:

General coverage: Products listed in the Diabetic Supplies section are a covered benefit based on the member's plan; products not listed require prior authorization.

See chunk 10

Preferred supplies and meter: FreeStyle glucose meters, lancets, test strips, and supplies are preferred and do not require prior authorization; Abbott will provide one glucose meter per member with no copay.one meter per member

See chunk 10

Needles and syringes: Embecta needles and syringes (sizes typically used for insulin) are preferred and covered; other sizes require prior authorization.

See chunk 10

This formulary excludes certain categories of products from coverage for Child Health Plus members. Notable exclusions include appetite suppressants/weight-loss medications, medications used for cosmetic purposes, and medical foods except when used to treat inborn errors of metabolism (for example, PKU). The formulary also excludes prenatal vitamins classified as medical foods, medications for sexual/erectile dysfunction, all medicines used to promote fertility for Child Health Plus members, and growth hormones prescribed for short stature. In addition, prescription medicines not recognized by the FDA without an NDC, prescription medicines not approved by the FDA, and drugs found DESI-disapproved by the FDA are excluded.

The excerpted formulary pages in this section present drug listings with assigned tiers and utilization management annotations (for example, PA, QL, AL, ST, LDD, and specialty notes). The document segment does not define clinical medical necessity rules or expanded coverage criteria here — it provides formulary rows and notes that identify where prior authorization, quantity limits, age limits, step therapy, or limited distribution may apply.

Some products in the formulary are designated OTC (over-the-counter) in the Notes field (examples include NARCAN NASAL LIQUID and other naloxone nasal products). An OTC annotation may affect how the product is dispensed or billed under the prescription benefit and should be considered when determining coverage or when submitting claims and prior authorization requests.

This portion of the formulary lists multiple products with tier assignments and Notes flags (e.g., DUPIXENT — Notes = PA, diagnostic and specialty product annotations). It does not contain standalone clinical exclusion statements; rather, it documents product-level utilization controls and specialty routing information that may require additional documentation or prior authorization.

The indexed section is an alphabetical index of drug names and page references. It contains drug name entries only and does not state explicit coverage exclusions or clinical criteria in these index lines.

Medicines used for purely cosmetic purposes and products excluded by state or federal law or because they lack medically accepted indications per FDA labeling are considered not covered for Child Health Plus members. The formulary explicitly treats such products as not covered / not medically necessary under the plan.

Codes, formulations, and device/product specs

Formulary strengths (listed)mixed

10000 UNIT/ML	Listed strength — requires prior authorization (PA); Tier 2
2000 UNIT/ML	Listed strength — requires prior authorization (PA); Tier 2
3000 UNIT/ML	Listed strength — requires prior authorization (PA); Tier 2
4000 UNIT/ML	Listed strength — requires prior authorization (PA); Tier 2

Prior authorizations, step therapy, documentation and denial risks

Prior Authorization

Prior Authorization Required

Independent Health requires prior authorization (PA) for many listed medicines and certain continuous glucose monitors (CGMs). To obtain coverage for any medicine that requires PA, a health care provider must submit a prior authorization request for a medical exception and receive Independent Health approval. Drugs that require prior authorization are identified by a "PA" flag in the formulary Notes field. Coverage will be denied if PA is required but not obtained.

PA flag in formulary Notes indicates prior authorization required
Prior authorization requests must be submitted by the prescribing provider for medical exception review
Coverage may be denied if PA is not approved prior to dispensing

Prior Authorization

Prior Authorization for Select Products

Prior authorization is required for a broad set of specialty, oncology, transplant, and other select products. Examples from the formulary include specialty biologics, certain oncology agents, transplant-related immunosuppressants, and selected injectables (many rows list "PA", sometimes with specialty exceptions). Some products also carry limited distribution (LDD) or specialty program (SP) annotations.

Notes flags and abbreviations

AL — Age Limit

AL — Age LimitPrescription medicines restricted by age for safety reasons

Usage in notesAL appears as a formulary note flag alongside other flags (e.g., QL, PA, ST)

ExamplesAL used with certain topical agents and other products in the formulary (see formulary entries)

PA — Prior Authorization Required

PA — Prior Authorization RequiredMedicine requires prior authorization; drugs listed with 'PA' require a prior authorization request submitted by the provider and approved by Independent Health

Denial riskCoverage will be denied unless a prior authorization request is submitted and approved for medicines that require PA

Step therapy rules and affected agents

Requirement	Notes
Try specified step agent first (ST flag)
Medicines listed with 'ST' require trial of a preferred or equally effective agent (often a generic) before Independent Health will cover the listed product.

Example product(s)	Notes
Certain opioid extended‑release products (e.g., morphine sulfate ER formulations)
Notes include 'ST' for morphine sulfate ER indicating a step therapy requirement before coverage.

Example product(s)	Notes
AIRSUPRA inhalation aerosol (albuterol HFA)
Listed with 'ST' (and QL) indicating step therapy applies to selected inhalation products.
Sertraline and other antidepressants (e.g., sertraline HCl oral tablet)
Sertraline entries include 'ST' indicating a required trial of preferred agent(s) prior to coverage of the listed formulation.

Example product(s)	Notes
Aprepitant (oral capsules) and EMEND oral suspension
Notes include 'ST' (e.g., aprepitant: 'ST; ST applies except'; EMEND oral suspension: 'ST; ST applies except'), indicating step therapy applies to these antiemetics.
Granisetron (oral tablet)
Granisetron entries include 'ST; QL' showing step therapy (and quantity limit) controls for coverage.

Flag(s)	Interpretation
AL (Age Limit)
An 'AL' note indicates an age restriction that may function as an access control prior to coverage approval.
QL (Quantity Limit)
'QL' denotes quantity limits that can act as utilization controls before coverage is approved.
LDD (Limited Distribution Drug)
'LDD' designates limited distribution which may restrict dispensing channels and serve as an access control prior to coverage.

Example product(s)	Notes
TRIVORA (28) oral tablet and other contraceptives
Some contraceptive entries show 'Notes = PA' or 'PA except dermatology' indicating prior authorization or specialty exceptions may apply before coverage.
FABIOR external foam and other dermatologic products
Formulary rows include 'PA; ST except' or 'PA; PA except dermatology' suggesting prior authorization or step edits with dermatology exceptions.

Flag type	Meaning / Action
ST
Products marked 'ST' require a prior trial of specified step agents before the listed product is covered; 'ST except' denotes exceptions to the step requirement for specified specialties.
ST except / ST applies except
Phrasing such as 'ST except' or 'ST applies except' identifies specialty or other exceptions to step therapy requirements.

Example product(s)	Notes / Requirement
Lenalidomide (oral capsule)
Listed with 'Notes = PA' indicating prior authorization is required for coverage.
RETACRIT, FULPHILA, UDENYCA (injectable/subcutaneous biologics)
These agents include 'PA' (and in some cases 'LDD' or 'DF') in the Notes field, indicating prior authorization and possible limited‑distribution or specialty routing are required.
Everolimus and sirolimus (immunosuppressants)
Entries show 'PA; PA except renal transplant surgeon' or similar, indicating PA is required with provider‑type exceptions documented.

Example product(s)	Notes
BRONCHITOL syringe kits / starter kits; ORAL TABLET THERAPY PACKS (e.g., ORKAMBI, KALYDECO packets)
Notes include 'PA' and 'PA; LDD' for many starter kits and therapy packs, indicating prior authorization and possible limited distribution requirements before coverage.
CHANTIX starting/continuing month pak and CHANTIX PAK ORAL TABLET
Entries include 'AL', 'PA', and 'PA; LDD' notes showing age limits, prior authorization, and limited distribution can apply to starter/therapy packs.

Quantity and dispensing limits

Examples — quantity limits

Examples of QL limitsSumatriptan and aprepitant are examples of medicines with quantity limitations (listed with 'QL')

30‑day basisQuantity limits are often expressed as a maximum per 30 days; check specific product row for exact amount

Formulary notationItems with quantity limits are annotated 'QL' in the formulary Notes

FreeStyle Libre sensors

FreeStyle Libre sensor limitUp to 2 sensors per 28‑day supply or 6 sensors per 84‑day supply

No PA for insulin usersFreeStyle Libre sensors available at retail without prior authorization for members using insulin multiple times daily

Where to obtain covered products

Note

Use VFC Program for vaccines for children ≤ 18 years

Vaccines for children 18 years and younger should be obtained through the New York Vaccines for Children (VFC) Program; pharmacists certified to vaccinate may administer vaccinations to adults per program rules.

VFC program supplies vaccines for children ≤ 18 years.
Pharmacists with vaccination certification may vaccinate adults 19+.

Scope and applicability

This formulary applies to pediatric members enrolled in Independent Health's Child Health Plus plan. It details covered products, preferred diabetic supplies and sensors, and the utilization controls that apply to many entries (for example, prior authorization (PA), step therapy (ST), quantity limits (QL), and age limits (AL)). Coverage is subject to the member's benefit and to applicable state and federal rules; drugs listed as covered without restriction may still require prior authorization if used for a non–FDA‑approved indication or with a non‑covered service.

Policy Summary

PayerIndependent Health

PolicyChild Health Plus Drug Formulary — Prescription Drug Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for medicines listed with 'PA' to avoid coverage denial.

SourceLink

On This Page

Excluded preparations: Bulk products and powders are excluded from coverage and are not eligible for compounding coverage.

Test strip quantity limits:

Diabetic test strips are limited to 100 per 30 days for non‑insulin dependent diabetics and 300 per 30 days for insulin dependent diabetics.

100 per 30 days (non‑insulin); 300 per 30 days (insulin)

Continuous glucose monitors — FreeStyle: FreeStyle Libre, Libre 2 and Libre 3 sensors are available at retail without prior authorization for members using short‑ or rapid‑acting insulin multiple times per day; if covered, members may fill up to two sensors per 28‑day supply or six sensors per 84‑day supply and one receiver per plan year subject to formulary limits.up to 2 sensors per 28‑day supply or 6 per 84‑day supply; one receiver per plan year

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Continuous glucose monitors — Dexcom: Dexcom G6 and G7 are non‑preferred and require prior authorization; if approved, members may fill up to three sensors per 30‑day supply, one Dexcom G6 wireless transmitter every 90 days (G7 includes built‑in transmitter), and one receiver per plan year.up to 3 sensors per 30‑day supply; one transmitter every 90 days; one receiver per plan year

See chunk 10

Specialty biologics and parenteral products commonly flagged PA (examples: FASENRA PEN, DUPIXENT, FULPHILA, RETACRIT, UDENYCA)
Oncology and hematology oral agents often flagged PA and sometimes LDD (examples in oncology drug rows)
Transplant agents (e.g., everolimus) may be PA or have provider-type exceptions (PA except renal transplant surgeon)
Some PA items also list LDD, MM, or specialty routing — follow the Notes field for distribution and program requirements

Prior Authorization

PA Required for Specific Products

Specific formulary entries explicitly annotated with "PA" require prior authorization; the Notes field may also include "PA except " indicating specialty exceptions for certain prescribers. Examples in the formulary include many anticonvulsants (e.g., vigabatrin), VALTOCO nasal doses, ketoconazole oral, itraconazole, selected antifungals (NOXAFIL), and specific nasal/CGM products. Providers should review the Notes column for each product to confirm PA requirements and any specialty exceptions.

Entries may show "PA; PA except " — specialty prescribers may be exempt from PA in some cases
Certain antifungals and antivirals are PA-listed (e.g., ketoconazole, itraconazole, NOXAFIL)
Some CGMs (Dexcom G6/G7) are non-preferred and require PA for specific member types (e.g., Child Health Plus)

Step Therapy

Utilization Management Flags (ST / QL / AL / LDD / DF)

Many formulary rows include utilization management flags beyond PA: step therapy (ST), quantity limits (QL), age limits (AL), limited distribution (LDD), and distribution/facility flags (DF). These flags can affect coverage decisions and may require additional documentation or adherence to step edits prior to approval.

ST = Step Therapy — try lower-cost or preferred agents first; products flagged ST may be denied without meeting step requirements
QL = Quantity Limits — claims exceeding QL may be modified or denied
AL = Age Limits — coverage may be restricted by member age
LDD/DF = Limited distribution or designated distribution channels — may require specialty pharmacy routing

Step Therapy

Step Therapy Requirements

Step therapy applies to many drug classes (e.g., some inhalation therapies, antidepressants, antiemetics, and certain analgesics). Entries marked with "ST" indicate a step edit that must be met before coverage of a nonpreferred product is approved. Providers should consult the Notes field to determine applicable step edits and any specialty exceptions.

ST entries may include "ST applies except " — specialty exceptions may override ST
Common ST examples: selected inhalers (AIRSUPRA), antiemetics (aprepitant/EMEND), and some opioid ER products

Documentation Required

Compounded Prescriptions

Compounded prescriptions: participating dispensing pharmacies must submit prior approval for compounded prescriptions costing more than $200. Compounded products under $200 do not require prior authorization if all other coverage requirements are met. Bulk powders and non‑covered compounding components are excluded.

Compounds > $200 require prior authorization
Compounds ≤ $200 do not require PA if other requirements are met
Coverage follows the Compounding Medication Products Policy; bulk products and powders excluded

Prior Authorization

Diabetic Supplies and CGMs

Diabetic supplies and CGMs: many preferred supplies (FreeStyle meters, strips, and sensors) are available without prior authorization where indicated; non‑preferred CGMs (e.g., Dexcom G6/G7 for some plans) may require PA. Review the Diabetic Supplies section and Notes to confirm whether a specific CGM or supply requires PA and any quantity limits.

FreeStyle Libre sensors available without prior authorization for insulin‑using members as described
Dexcom G6/G7 may be non‑preferred and require PA for Child Health Plus members
Other diabetic supplies not listed in the section generally require prior authorization

Documentation Required

Formulary Notes, Specialty Exceptions and Routing

Formulary Notes and specialty routing: many Notes entries include clinical routing (e.g., oncology, neurology, dermatology), "PA except ", or specific documentation expectations (MM, LDD, DF). These indicate where specialty-level review or additional clinical documentation may be required and may authorize exceptions for certain prescribers.

"PA except " may exempt certain specialty prescribers from PA (e.g., cystic fibrosis specialists, renal transplant surgeons)
Notes such as Oncology, Rheumatology, Neurology indicate specialty review pathways
LDD and DF indicate limited distribution or designated distribution (may require specialty pharmacy)

Denial Risk

Documentation and Denial Risks for Flagged Entries

Documentation expectations and denial risks: products annotated with PA, QL, ST, MM, or LDD typically require supporting clinical documentation at the time of PA submission. Without appropriate documentation or failure to meet step/quantity requirements, claims may be denied or modified.

Include diagnosis, prior treatments, rationale for medical necessity when submitting PA
Failure to meet ST/QL requirements or missing documentation may result in claim denial
Products with MM, LDD, or DF may require program-specific forms or specialty pharmacy coordination

Documentation Required

Prescribing and Submission Details — Formulation & Strength

Provider action reminders: always specify formulation, strength, and quantity on PA requests. Some formulary entries list multiple formulations/strengths and provider‑type exceptions; precise prescriber documentation helps expedite review and avoid denials.

Specify exact formulation, strength, and dosing schedule on requests
Refer to the Notes field for provider‑type exceptions (e.g., "PA except renal transplant surgeon")
When LDD or specialty pharmacy is listed, coordinate dispensing through the specified channel

Note

Index — Lookup Guidance

Index notice: the Index section lists drug names and page references only and does not itself state authorization rules. Always cross‑check the drug entry in the formulary tables for Notes indicating PA, ST, QL, AL, LDD, MM, DF or other utilization controls.

Index entries are for lookup only — consult the formulary rows for utilization flags
Do not assume lack of PA based on the index alone

Note

No Prior Authorization Listed in Some Sections

Section areas with no PA rules: some parts of the index or listings simply enumerate drug names without Notes; these blocks do not by themselves impose prior authorization but may correspond to formularies elsewhere in the document. Confirm the product row in the Additional Formulary Information for any utilization flags.

A plain index entry without Notes does not guarantee no PA — verify in the detailed formulary sections

Notes usage'PA' appears in the formulary Notes field and may be combined with other flags (e.g., 'PA; LDD', 'PA except')

ST — Step Therapy

ST — Step TherapyRequires trial of specified preferred agent(s) before coverage of the listed medicine (flagged 'ST' in formulary Notes)

ExamplesST applies to certain opioid extended‑release products and selected antiemetics (e.g., aprepitant, EMEND oral suspension) as indicated in Notes

Interaction with PA/QLST may be used alongside PA or QL flags and may result in claim modification or denial if requirements unmet

QL — Quantity Limits Apply

QL — Quantity Limits ApplyProduct is covered up to a specific quantity per time period (e.g., per 30 days) as indicated by 'QL' in formulary Notes

Package rulesFor pre‑packaged items, one package size is allowed per fill; formulary QL takes precedence when applicable

ExamplesExamples include sumatriptan and aprepitant; various topical products (e.g., clotrimazole‑betamethasone cream) show QL notes

DF — Dental Formulary

DF — Dental FormularyMedicines covered when prescribed by a dental provider (flagged 'DF' in formulary Notes)

Notes placementDF appears in the formulary Notes column alongside other utilization flags where applicable

Example entriesSome injectable or specialty products include DF in their notes where dental prescribing is relevant

LDD — Limited Distribution Drugs

LDD — Limited Distribution DrugsSpecialty medicines obtainable only through designated specialty pharmacies; flagged 'LDD' in the formulary Notes

Program examplesProducts such as JAKAFI and some oncology agents are listed with 'PA; LDD' indicating limited distribution plus PA requirements

Supply channel implicationCoverage and dispensing may be restricted to specialty pharmacy channels per manufacturer distribution limits

PA — Prior Authorization

Prior Authorization — coverage requirementCoverage requires insurer approval prior to dispensing when 'PA' is specified in the formulary Notes

Provider actionProviders must submit a prior authorization request for PA‑flagged drugs to avoid denial of coverage

PA modifiersFormulary may include modifiers like 'PA except' to denote specialty exceptions

ST — Step Therapy

ST — Step Therapy requirementA trial of preferred/lower‑cost agents is required before covering the specified drug when 'ST' appears in Notes

Opioid exampleSome opioid extended‑release products include 'ST' indicating step edits apply prior to coverage

ST exceptionsFormulary may specify 'ST except' or specialty exceptions for certain agent classes

QL — Quantity Limit

QL — Quantity Limit definitionMaximum allowable quantity per defined period without prior approval; indicated by 'QL' in Notes

ApplicationQLs apply to many products including some topical, antiviral and other classes shown in the formulary

PrecedenceWhen QL is designated it takes precedence over pack size limits for pre‑packaged items

AL — AL (formulary annotation)

AL — administrative/formulary noteAppears as an annotation in formulary notes (e.g., used with topical agents); may indicate age or other administrative limitation

InterpretationIn this document AL is used as a utilization note flag and the specific meaning may be context dependent (age limit or similar restriction)

Cross‑referenceAL is listed alongside other flags (PA, QL, ST, LDD) in the formulary Key

MM — MM (notes flag)

MM — Notes flagMay indicate 'medication management' or a special administrative/monitoring note (document shows 'MM' as a notes flag)

Contextual useMM appears in formulary entries where additional management or monitoring may be needed (see specific product Notes)

Not a standalone coverage ruleInterpretation based on Notes flag usage; check product Notes for required documentation

OTC — Over‑the‑counter

OTC — Over‑the‑counterAvailable without prescription; noted for certain naloxone products (e.g., NARCAN NASAL LIQUID marked OTC)

Coverage implicationOTC designation may affect coverage or dispensing process — see formulary Notes for details

ExamplesNARCAN NASAL LIQUID, OPVEE NASAL SOLUTION, RIVIVE NASAL LIQUID show OTC notes in formulary

Notes abbreviations

Notes abbreviations — key listPA = prior authorization; QL = quantity limit; AL = age limit or additional limitation; ST = step therapy; DF = dental formulary; LDD = limited distribution

Usage in formularyThese abbreviations appear in the Notes column to denote utilization management and exceptions

Cross‑check requiredRefer to the specific formulary row for combined flags (e.g., 'PA; LDD', 'PA except') to understand requirements

PA — Prior Authorization

PA — Prior Authorization (definition)Coverage requires approval by the plan prior to dispensing when 'PA' is specified in the formulary Notes

Provider responsibilityProviders must submit prior authorization requests for PA‑flagged drugs to obtain coverage

Forms and exceptionsFormulary may show exceptions (e.g., 'PA except') or combine PA with other flags (e.g., 'PA; LDD')

QL — Quantity Limit

QL — Quantity Limit (definition)Product has limits on the amount that may be dispensed over a time period as indicated by 'QL'

ImplementationQLs are applied to many products including topical agents and specific systemic therapies — check the product row for exact limits

Claims impactClaims may be modified or denied if the quantity exceeds the QL without authorization

ST — Step Therapy

ST — Step Therapy (definition)Lower‑cost or preferred agents must be tried before coverage of the specified product when 'ST' appears in Notes

Provider actionDocument prior trials of required agents when submitting requests for ST‑flagged drugs

ExamplesST applied to some antiemetics and other agents (e.g., aprepitant, EMEND oral suspension); see Notes for specifics

LDD — Limited Distribution Drug

LDD — Limited Distribution Drug (definition)Product distribution may be limited to specific channels and specialty pharmacies (flagged 'LDD')

ExamplesSome oncology and specialty oral agents list 'PA; LDD' indicating limited distribution plus prior authorization

ProcurementProviders may need to use designated specialty pharmacies for dispensing LDD‑flagged products

AL — Administrative label (AL)

AL — administrative label usageAppears in Notes as an administrative label (document indicates use with certain topical agents); likely an internal coverage annotation

Contextual meaningAL may indicate age limit or other internal allowance depending on product context in the formulary

Check product rowInterpretation requires checking the specific formulary entry where AL is applied

Index entries

Index entries presentAlphabetical index entries are included in the document to locate formulary items

ScopeIndex lines list many product names with page references; this section is an index excerpt

UseUse the index to find detailed formulary rows elsewhere in the document

Formulary index

Formulary index includedA formulary index is present listing drug names alphabetically to aid lookup

Partial excerptIndex lines in this extract are partial; full listings continue in subsequent chunks

NavigationIndex entries include page references to detailed formulary entries elsewhere in the document

Receiver allowanceOne receiver per plan year when covered

Dexcom G6 sensors

Dexcom G6/G7 sensor limitUp to 3 sensors per 30‑day supply if approved

Dexcom transmitter/receiver limitsOne Dexcom G6 wireless transmitter every 90 days (G7 includes built‑in transmitter); one receiver per plan year

PA statusDexcom G6 and G7 are non‑preferred and require prior authorization for Child Health Plus members

AIRSUPRA INHALATION AEROSOL / albuterol HFA

AIRSUPRA / albuterol HFAQuantity limit (QL) present for selected inhalation products as noted in the formulary

Check NotesRefer to the product row for exact QL details and any associated flags

Formulary placementListed under Additional Formulary Information for inhalation/bronchodilator agents

escitalopram oxalate oral solution 5 mg/5ml

Escitalopram oral solution QLEscitalopram oxalate oral solution 5 mg/5 mL is noted with a quantity limit (QL) in the formulary

Formulary rowCheck the specific product row for the QL details and any other Notes

Therapeutic classListed under antidepressants with QL annotations for liquid formulations

VIVITROL INTRAMUSCULAR

VIVITROL INTRAMUSCULAR — QLVIVITROL intramuscular is listed with a quantity limit (QL) in the formulary Notes

Multiple entriesVIVITROL appears in more than one formulary line with QL indicated

Class contextListed among opioid‑related and addiction treatment agents; check row for course‑based limits

VIVITROL INTRAMUSCULAR — QL noted

VIVITROL — QL notedFormulary Notes explicitly indicate QL for VIVITROL intramuscular formulations

TieringVIVITROL entries include tier assignments and QL flags in Additional Formulary Information

Provider actionRefer to QL when requesting coverage for VIVITROL to ensure authorization if exceeding limits

doxylamine-pyridoxine

doxylamine‑pyridoxine — QLDoxylamine‑pyridoxine oral tablet is indicated with a quantity limit (QL) in the formulary Notes

Therapeutic contextListed under antiemetics/related agents with QL in certain presentations

Check product rowRefer to the specific formulary entry for exact QL or related flags

TAMIFLU (capsule, suspension)

TAMIFLU — QLTAMIFLU (capsule and suspension) is noted with a quantity limit (QL) in the formulary

Course‑based limitsQL likely reflects course‑based dispensing for antiviral therapy; check product row for details

Formulary locationListed among antivirals with QL/AL annotations in Additional Formulary Information

clotrimazole-betamethasone external cream

clotrimazole‑betamethasone cream — QLClotrimazole‑betamethasone external cream is listed with a quantity limit (QL) in the formulary Notes

Topical formulationListed under dermatology/external agents; check the specific Notes for dispensing limits

Claims implicationDispensing beyond QL may require prior authorization or be denied at claim adjudication

salicylic acid external shampoo / cleanser / gel entries

Salicylic acid external products — QL indicatedSome salicylic acid external shampoos/cleansers/gels are annotated with quantity limits (QL) in the formulary

Product typesIncludes external shampoo, cleanser, and gel presentations used in dermatology

VerificationRefer to the product row for exact QL and any associated Notes (e.g., PA) before dispensing

XROMI ORAL SOLUTION; entries with QL/AL notes

XROMI ORAL SOLUTION — QL/AL notesXROMI oral solution entries include quantity limits (QL) and age limits (AL) in the Notes

Formulary contextListed with device/supply references (e.g., OMNIPOD kits) and QL annotations

ActionCheck product row for specific age and quantity restrictions before approval/dispensing

epinephrine injection solution

Epinephrine injection solution — QLEpinephrine injection solution is listed with a quantity limit (QL) in the formulary Notes

Auto‑injectorsEpinephrine auto‑injector presentations are listed with tiering; check Notes for QL specifics

Use caseQL may apply per year or per course depending on formulation — verify on product row