CurrentIndependent HealthPolicy N/A

Independent Health Child Health Plus Drug Formulary — Coverage Criteria

Formulary and coverage rules for prescription drugs under Independent Health's New York State Child Health Plus plan, including prior authorization, step therapy, quantity limits, age limits, and specialty drug distribution; affects Child Health Plus members, prescribing providers, and pharmacies.

Policy Summary

PayerIndependent Health

PolicyChild Health Plus Drug Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateRevised August 2025

Key ActionSubmit prior authorization requests for medicines listed with 'PA' — requests must be submitted by the health care provider and approved by Independent Health.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Child Health PlusPlan

PA, ST, QL, AL, DF, LDDKey flags

100/300Test strip limits

Max 4/30dOpioid fill limit

Dexcom PACGM products

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Formulary Coverage Criteria

Coverage follows formulary listings with utilization management and exclusions as specified below.

Formulary coverage general rule: A drug is covered when it is listed as covered on the Independent Health Child Health Plus formulary and is used for medically‑accepted indications consistent with FDA labeling and New York State Medicaid guidelines; providers should verify the formulary association for the member's plan before prescribing.

See chunk 0 and 12

Prior authorization (PA): Medicines annotated with 'PA' require a prior authorization request submitted by the health care provider and approval by Independent Health before coverage is provided; failure to obtain PA will result in denial of coverage.

See chunks 1 and 43 in brief references

Step therapy (ST): Medicines annotated with 'ST' require a trial of specified preferred alternative(s) (typically generics or lower‑cost agents) prior to coverage of the requested medication; documentation of failure or intolerance to step agents may be required.

See chunk 2

Quantity limits (QL): Medications with 'QL' are subject to quantity limits as listed on the formulary; for prepackaged items one package size is allowed per fill unless an explicit formulary QL overrides that restriction.

See chunk 3

Age restrictions (AL): Drugs annotated 'AL' carry age restrictions based on FDA labeling; absence of an AL flag on the formulary does not negate applicable FDA age limitations.

See chunk 4

Compounded medications: Compounded prescriptions must be prepared by a participating pharmacy and include at least one prescription component. Compounds costing $200 or less do not require prior authorization if all other requirements are met; compounds costing more than $200 require prior authorization.

See chunk 9

Diabetes supplies and monitoring devices: Preferred diabetes supplies (Embecta needles/syringes; FreeStyle meters, strips, lancets and sensors) are covered per the formulary with specified quantity rules; FreeStyle Libre sensors: up to 2 sensors per 28‑day supply (or 6 per 84 days) and one receiver per plan year. Non‑preferred CGMs (Dexcom G6/G7) require prior authorization; if approved, Dexcom limits apply (up to 3 sensors per 30 days; one transmitter every 90 days; one receiver per plan year). Diabetic test strips limits: 100 per 30 days for non‑insulin dependent members and 300 per 30 days for insulin dependent members.

See chunk 10

Opioid fill limit: Opioid medications are limited to a maximum of four (4) fills per 30 days.Max 4 fills / 30 days

See chunk 12

Coverage exclusions: The formulary excludes appetite suppressants/weight‑loss medications; medications for cosmetic purposes; medical foods except to treat inborn errors of metabolism; prenatal vitamins classified as medical foods; medications for sexual/erectile dysfunction; fertility‑promoting medicines for Child Health Plus members; growth hormone when prescribed for short stature; prescription medicines not recognized by the FDA without an NDC; and prescription medicines not approved by the FDA. Drugs excluded by state or federal law and DESI‑classified ineffective drugs are also not covered.

See chunk 12

Non‑FDA or non‑standard use: Medications listed as covered without restriction may still require authorization or may not be covered if used for a non‑FDA‑approved indication or in conjunction with a non‑covered procedure/treatment; coverage is limited to medically‑accepted indications per FDA labeling and applicable Medicaid guidelines.

See chunk 12

Specialty distribution / site‑of‑care: Some specialty medications are limited distribution and must be obtained through designated specialty pharmacies or channels; providers and pharmacies must follow the formulary's limited distribution instructions where noted.

See brief site_of_care and chunk 6 in brief references

The formulary excludes several categories of medications from coverage for Child Health Plus members. Specifically, appetite suppressants/weight-loss medications, medications used for cosmetic purposes, and medical foods other than those to treat inborn errors of metabolism (e.g., PKU) are excluded. Prenatal vitamins classified as medical foods are not covered. Coverage also excludes medicines used to treat sexual or erectile dysfunction, fertility-promoting medicines for Child Health Plus members, growth hormones when prescribed for short stature, medications excluded by state or federal law, prescription medicines without an FDA-recognized NDC, and medicines not approved by the FDA.

Certain formulary entries that carry a "PA except" annotation reserve the exception for prescribers in specified specialties. Examples include inhaled tobramycin and TOBI PODHALER entries noted as "PA; PA except for Cystic fibrosis specialists". When a PA exception is limited in this way, the prescriber must meet the specialist requirement documented in the formulary notes for the exception to apply.

Some formulary lines imply restricted durations or conditions (for example, notes such as "PA required for" or references to shorter allowable durations like statements mentioning "than 14 days except"), indicating limited treatment durations or special authorization requirements may apply. The extract does not provide complete numeric duration rules for all products; providers should follow the specific Notes field for each drug when present.

Drugs used for non–FDA-approved indications or provided in conjunction with procedures or treatments that are not covered under the member's health contract may not be covered, even if the drug appears on the formulary as covered without restriction. Coverage is limited to medically accepted indications per FDA labeling and applicable New York State Medicaid guidance.

Formulary Entries & Product Coding

Formulary drug entries (sample)mixed

MOUNJARO SUBCUTANEOUS	Code entry for MOUNJARO subcutaneous formulary listing (GLP-1 receptor agonist; ensure mapping to appropriate NDC/HCPCS as required).
ADMELOG INJECTION SOLUTION	Listed under Antidiabetics; notes: QL / ST on some presentations.
OZEMPIC (1 MG/DOSE)	Listed under Antidiabetics; example mapping present in source.

Specialty / Injectable Agentsmixed

FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR	Specialty biologic with PA noted in source.
FRAGMIN SUBCUTANEOUS	Listed with PA and tier variations.
enoxaparin sodium injection	Multiple entries; some with Tier 1 designation.

Antidiabetic Agentsmixed

ADMELOG INJECTION SOLUTION	Tier 2; QL noted for some presentations; ST noted for others.
ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN	Multiple notes including QL and ST in source.
OZEMPIC (1 MG/DOSE)	Listed under antidiabetics in extract.
BAQSIMI NASAL	Included in antidiabetic section as glucagon rescue product; AL noted for some entries.
MOUNJARO SUBCUTANEOUS	GLP-1/GIP receptor agonist included in antidiabetic formulary listings — code entry added to ensure completeness.

Diabetic test strips — quantity limits (non-insulin / insulin)

Diabetic test strips (non-insulin)Limit: maximum 100 per 30 days

Diabetic test strips (insulin-dependent)Limit: maximum 300 per 30 days

FreeStyle Libre sensors — supply limits and receiver rule

FreeStyle Libre sensorsFill up to 2 sensors per 28-day supply or 6 sensors per 84-day supply (subject to formulary limits); one receiver per plan year

FreeStyle Libre receiver ruleOne receiver per plan year

Dexcom sensors and transmitter — sensor/transmitter/receiver limits

Dexcom G6/G7 sensorsIf approved, fill up to 3 sensors per 30-day supply

Dexcom transmitterOne Dexcom G6 wireless transmitter every 90 days (G6 7 sensors may include built-in transmitter)

Dexcom receiverOne receiver per plan year

Opioids — fill limits

Lost/Stolen/Damaged MedicationsReplacement is member responsibility; PA cannot be used for early refills for lost/stolen/damaged meds or vacation supplies

Vacation suppliesNot covered under this benefit

Duration limits — referenced duration constraints (numeric values not present in extract)

Duration limits (referenced)Referenced duration constraints apply as noted in formulary entries (numeric values may be specified elsewhere in plan documents)

Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Independent Health requires prior authorization (PA) for many products listed in the formulary. Providers must submit a prior authorization or medical exception request and receive approval before the plan will cover medicines labeled PA. Denials are possible if PA is not obtained.

PA flag appears in formulary Notes ("PA").
Compounded prescriptions > $200 require PA (compounds ≤ $200 do not require PA if other requirements met).

Prior Authorization

Prior Authorization + Quantity Limits

Some drugs require both prior authorization and an enforced quantity limit (QL). When Notes include both PA and QL, providers must obtain PA and be aware of the plan’s quantity limits when authorizing refills or dispensing initial fills.

Examples: TOBI PODHALER and nebulized tobramycin entries include PA and QL.
Fondaparinux sodium is listed with PA and QL.

Step Therapy

Step Therapy Requirement

Step therapy (ST) requires trial of preferred alternatives before coverage of non-preferred agents. Where the formulary Notes include ST, the provider should follow the step edits and document prior trials of preferred agents.

Examples: certain opioid transdermal doses and ER opioid formulations include ST.
Topical agents and antidiabetics may include ST entries.

Documentation Required

Specialist Authorization Notes

Specialty or prescriber restrictions are noted for certain products — some PAs are waived only when prescribed by a specialist. Providers should confirm prescriber specialty and include specialty documentation when requesting PA.

TOBI PODHALER and inhaled/nebulized tobramycin: PA except for Cystic Fibrosis specialists.
Valganciclovir: PA; PA except Infectious Disease, Nephrology.
Many neurologic and specialty injectables note "PA except neurology" or require specialty prescriber documentation.

Documentation Required

Specialty Documentation for PA Exceptions

Some products are labeled PA except for care managed by specified specialties (see formulary Notes). When a PA exception for specialty care applies, include documentation of specialty care in the PA submission to expedite review.

Documenting cystic fibrosis, infectious disease, nephrology, neurology, urology, or dermatology specialty status may satisfy an exception noted in the formulary.
Provide clinic notes, prior specialist visits, or membership in a specialty program where applicable.

Note

Diabetes Supplies — Authorization and Limits

Certain devices and diabetes supplies have specific PA rules and quantity limits. Abbott FreeStyle meters and supplies are preferred and often do not require PA; other CGM products (e.g., Dexcom G6/G7) may be non-preferred and require PA depending on plan and member type.

FreeStyle meters and supplies are preferred and do not require PA; Abbott provides a no-copay meter via a manufacturer program.
FreeStyle Libre sensors: covered at retail without PA for members using insulin; fill limits apply (e.g., up to two sensors per 28-day supply).
Dexcom G6/G7 are non-preferred and may require PA (noted for Child Health Plus members).

Documentation Required

Required Supporting Documentation

Provider submissions must include supporting documentation to demonstrate medical necessity and compliance with step-therapy requirements. Include clinical notes, prior medication trials, specialty consultation notes, and any relevant lab or diagnostic information.

Medical necessity rationale and documentation of prior drug trials where ST applies.
Specialist consult notes when a PA exception for a specialty is claimed.
For compounds > $200 include cost documentation and component prescriptions.

Note

OTC / AL / LDD / Additional Limits

Some formulary entries use other handling flags (AL, LDD, MM, OTC) which affect coverage or distribution. Providers should review Notes for AL (age limitation), LDD (limited distribution drug), MM (manufacturer management), and OTC designations and follow the corresponding workflows.

Examples: OTC (NARCAN NASAL LIQUID), AL (age-limited products), LDD (e.g., VISTOGARD, TYMLOS, SOMAVERT).
Follow limited distribution pathways when Notes specify LDD.

Prior Authorization

Follow Prior Authorization Instructions Where Noted

Follow the formulary and prior authorization pathways exactly where noted. When a product’s Notes direct a specific PA pathway (e.g., specialty pharmacy, limited distribution, or specialist exception), use that pathway to avoid delays or denial.

Examples: products marked SP should be routed to the specialty pharmacy.
Follow PA instructions for starter/therapy packs and prefilled kits as indicated in Notes.

Prior Authorization

PA for Starter Packs, Therapy Packs, and Kits

Some formulary segments include starter packs, therapy packs, or device kits that are PA‑required or have special handling. These entries may also carry LDD or QL designations — account for those when authorizing initial supplies.

XARELTO starter packs, therapy packs, and several cystic fibrosis or neurology starter kits note PA or PA; LDD.
Starter/therapy packs may have unique quantity/dispensing rules and require specific documentation.

Note

No Authorization or Denial Criteria in Index

The formulary index is informational and does not contain specific authorization or denial criteria. For authorization rules and required documentation, refer to the formulary Notes and the PA submission instructions elsewhere in the plan materials.

Index lists product locations but does not replace PA documentation requirements.
Use the formulary Notes and payer PA instructions to determine coverage requirements.

Step Therapy Rules and Applicable Agents

Requirement	Description
Step therapy (ST)	Medications marked 'ST' require a trial of specified preferred alternative(s) (typically generics or lower‑cost agents) before coverage of the requested non‑preferred medication.

Agent / Class	Note
Fentanyl transdermal patch (72 hour)	Notes = ST (step therapy) for certain strengths; some entries also include PA or specialty exceptions.
Extended‑release opioid/abuse‑deterrent tablets (e.g., certain ER formulations)	Notes = ST applied to selected ER/abuse‑deterrent opioid products as indicated in the formulary entries.

Formulary Entry / Example	Step Therapy Flag
Multiple formulary entries across classes (example: starter/therapy packs, anticonvulsants)	Notes include 'ST' for select entries; specific step sequences not provided in this extract.
Antidiabetics cluster (see ADMELOG entries)	Some antidiabetic entries list 'ST' in Notes indicating step therapy applies, but detailed step sequence is not listed.

Agent / Product	Notes (ST presence)
ADMELOG injection solution / ADMELOG SoloStar	Notes include 'ST' on some ADMELOG entries (also QL on other ADMELOG entries).
Other agents in same clusters (antihypertensives, etc.)	Some entries in adjacent groups note 'ST' indicating step therapy may apply to certain agents within these clusters.

Topical Product	Formulary Note
Calcipotriene external solution / ointment	Notes = PA; ST (step therapy) noted for some calcipotriene topical formulations.
Desonide external cream	Notes = ST for desonide external cream in the formulary entries.
Clotrimazole‑betamethasone topical	Notes include QL for some formulations and ST noted for select topicals in the cluster.

Annotation	Implication for Step Edit
AL (Age Limit)	Appears as an access/step‑edit flag; AL annotations imply age‑based access rules that may act similar to step edits in the authorization workflow.
LDD (Limited Distribution Drug)	LDD notes indicate limited distribution channels and may trigger specialized step‑edit or prior authorization workflows; specific step therapy logic not provided here.
PA (Prior Authorization)	PA annotations alongside AL/LDD suggest additional authorization requirements that function with step edits; detailed step sequences are not specified in this extract.

Specified Quantity Limits & Supply Rules

Diabetic test strips — 100 (non-insulin) / 300 (insulin)

Non‑insulin users100 test strips per 30 days

Insulin users300 test strips per 30 days

SourceDiabetic Supplies section — Independent Health formulary

FreeStyle Libre sensors — 2 per 28 days or 6 per 84 days

28‑day supplyUp to 2 FreeStyle Libre sensors per 28 days

84‑day supplyUp to 6 FreeStyle Libre sensors per 84 days

ReceiverOne receiver per plan year

Dexcom sensors — up to 3 sensors per 30 days; transmitter every 90 days; receiver per plan year

SensorsUp to 3 Dexcom sensors per 30 days if approved

TransmitterOne Dexcom G6 wireless transmitter every 90 days

ReceiverOne receiver per plan year

TOBI PODHALER / tobramycin inhalation nebulization — QL noted

ProductTOBI PODHALER INHALATION / tobramycin inhalation nebulization solution

NotesAnnotated with QL (quantity limit) and PA; PA except for Cystic fibrosis specialists in source

ActionPrior authorization and quantity limits apply as indicated in formulary notes

fondaparinux sodium — QL noted (unspecified)

Productfondaparinux sodium

NotesFormulary entries include 'PA; QL' or 'Notes = PA; QL' indicating quantity limits apply (specific QL unspecified in extract)

ImplicationPrior authorization plus quantity limits may trigger coverage restrictions or denials if criteria not met

escitalopram oral solution — QL noted (unspecified)

Productescitalopram oxalate oral solution

NotesListed with 'QL' in formulary notes; specific quantity limit not provided in this extract

Coverage implicationQuantity limits apply — consult full formulary entry for numeric limits

ADMELOG injection solution — QL noted

ProductADMELOG injection solution / ADMELOG SoloStar

NotesEntries include 'QL' and some entries note 'ST' (step therapy) for ADMELOG formulations

Coverage implicationQuantity limits apply; step therapy may also apply for certain ADMELOG formulations

VIVITROL intramuscular — QL noted

ProductVIVITROL intramuscular

NotesFormulary notes indicate 'QL' for VIVITROL intramuscular formulations

ImplicationQuantity limits apply — refer to full formulary for numeric limits

TAMIFLU oral capsule / suspension — quantity/limits fragment

ProductTAMIFLU oral capsule / suspension

NotesListed in formulary; quantity/limit fragment present but specific QL not provided in this extract

ActionConsult full formulary entry for any specific quantity limits or prior authorization requirements

ELLA oral tablet — QL noted

ProductELLA oral tablet

NotesFormulary notes include 'QL' indicating a quantity limit applies

Coverage implicationExceeding the quantity limit may trigger denial; see full formulary for numeric limits

calcipotriene external ointment and other topicals — QL noted

ProductsCalcipotriene external ointment and multiple topical agents

NotesSome topical entries carry 'QL' (quantity limits) and/or 'ST' (step therapy) in formulary notes

ActionFollow formulary notes for quantity and step‑therapy restrictions on topical agents

salicylic acid external shampoo — QL noted

Productsalicylic acid external shampoo

NotesListed with 'QL' in formulary notes

ActionQuantity limits apply — consult the full formulary for specifics

sumatriptan succinate subcutaneous auto-injector — quantity limits fragment

Productsumatriptan succinate subcutaneous auto‑injector

NotesFormulary indicates 'QL' and 'LDD' for some auto‑injector entries; numeric limit not shown in extract

ActionQuantity limits or limited distribution designation may apply; confirm full formulary entry before dispensing

lofexidine hcl oral tablet — QL indicated

Productlofexidine hcl oral tablet

NotesListed with 'QL' in formulary notes (also annotated with PA and AL in source)

Coverage implicationQuantity limits and prior authorization/age limits may apply; see full entry for details

Abbreviations & Flags Used in the Formulary

PA — Prior Authorization (abbreviation definition)

PAPrior Authorization Required

STStep Therapy

QLQuantity Limits

ALAge Limit

DFDental Formulary

LDDLimited Distribution Drugs

ST — Step Therapy (abbreviation definition)

STStep Therapy

MeaningRequires trial of specified preferred alternatives before coverage of non‑preferred agents

SourceKey definitions in formulary 'Key' section

QL — Quantity Limits (abbreviation definition)

QLQuantity Limits — coverage limited to a specified quantity/timeframe

Usage'QL' appears in Notes for many products (e.g., VIVITROL, escitalopram solution, salicylic acid shampoo)

ImplicationExceeding QL may trigger denial or require prior authorization per formulary notes

AL — Age Limit (abbreviation definition)

ALAge Limit

UsageIndicates age‑based restrictions in formulary entries (e.g., certain products annotated 'AL')

ImplicationAge limits are applied consistent with FDA labeling and formulary notes

DF — Dental Formulary (abbreviation definition)

DFDental Formulary

MeaningDenotes items associated with dental coverage where applicable

ContextUsed as an abbreviated note within the formulary 'Key'

LDD — Limited Distribution Drugs (abbreviation definition)

LDDLimited Distribution Drugs — special distribution channel may apply

UsageAppears alongside PA or in Notes for specialty products and starter/therapy packs

ImplicationMay require designated specialty pharmacy or vendor per formulary entries

PA — Prior Authorization (alternate chunk locations)

PA (alt)Prior Authorization — coverage requires payer approval prior to dispensing (alternate reference)

ContextUsed in formulary Notes to indicate PA requirement for many products

Denial riskFailure to obtain PA will result in denial of coverage

QL — Quantity Limit (alternate chunk locations)

QL (alt)Quantity Limit — coverage limited to specified quantity/timeframe (alternate references show QL on topicals and injectables)

ExamplesVIVITROL intramuscular, salicylic acid external shampoo, ciclopirox entries annotated with QL

ImplicationQL entries may require adherence to numeric limits or prior authorization for overrides

ST — Step Therapy (alternate chunk locations)

ST (alt)Step Therapy — requires trial of preferred alternatives before coverage (alternate references)

ExamplesPropafenone and some topical/antidiabetic entries show 'ST' in Notes

ImplicationProviders must document failure or intolerance of step agents per formulary requirements

Tier — formulary tier definition reference

TierFormulary tier indicating cost‑sharing level (e.g., 1, 2, or unassigned)

UsageTier information appears in formulary rows and affects member cost‑sharing

SourceMultiple formulary entries across chunks include Tier annotations

PA / QL / AL / ST / OTC / LDD — aggregated abbreviations list

Abbreviations aggregatedPA / QL / AL / ST / OTC / LDD — common formulary note abbreviations and meanings

SourceDefined in formulary 'Key' and reiterated across Additional Formulary Information entries

ImplicationInterpret abbreviations on product rows to determine authorization, limits, age, or distribution requirements

PA — Prior Authorization (alternate chunk)

PA (alt2)Prior Authorization — coverage requires pre‑approval (alternate chunk)

ContextUsed on topical and other product entries to indicate PA requirement

ActionSubmit PA per payer process to avoid denial

QL — Quantity Limit (alternate chunk)

QL (alt2)Quantity Limit — limits on dispense quantity or frequency (alternate chunk)

ContextNoted for salicylic acid shampoo and other dermatology products

ImplicationProviders should verify allowed quantity per fill and timeframe

ST — Step Therapy (alternate chunk)

ST (alt3)Step Therapy — requires trial of preferred therapy(s) first (alternate chunk)

ExamplesSome antidiabetic entries (ADMELOG) and propafenone entries annotated with ST

ActionDocument trials of preferred agents when requesting coverage for ST‑listed products

LDD — Limited Distribution Drug (alternate chunk)

LDD (alt)Limited Distribution Drug — special distribution channel may apply (alternate chunk)

ExamplesStarter packs and specialty injectables are annotated with LDD and PA in these sections

ImplicationMay require designated specialty pharmacy or vendor for fulfillment

PA — Prior Authorization (alternate chunk)

PA (alt4)Prior Authorization — coverage requires payer approval before dispensing (additional alternate chunk)

ExamplesMultiple injectable and specialty products show 'PA' in Notes across segments

ActionProviders must submit PA requests per payer process to avoid denials

AL — AL as access/step-edit flag (alternate chunk)

AL (access flag)AL may appear as an access/step‑edit flag in formulary Notes

UsageIndicates age restrictions or administrative access flags impacting authorization workflow

ExampleEntries such as deferasirox and others include AL annotations

LDD — Limited Distribution Drug (alternate chunk)

LDD (alt2)Limited Distribution Drug — restricted channel or vendor (alternate reference)

UsageAppears with PA for specialty products and starter packs in formulary entries

ImplicationMay affect where and how the product is dispensed (specialty pharmacy requirements)

OpenPayer

Independent Health Child Health Plus Drug Formulary — Coverage Criteria

Formulary Coverage & Exclusions

Formulary Entries & Product Coding

Authorization, Step Therapy, and Documentation Requirements

Step Therapy Rules and Applicable Agents

Specified Quantity Limits & Supply Rules

Specialty Pharmacy & Vaccination Site Rules

Policy Background and Scope

Abbreviations & Flags Used in the Formulary