Independent Health Child Health Plus Formulary Coverage

Coverage Summary

General Coverage Conditions and Exceptions

Covered when ALL of the following general coverage conditions and exceptions are met:

ALL of the following

Formulary applicability: Drug coverage applies to medicines listed on the Independent Health Child Health Plus formulary for eligible members; verify plan-specific benefits before filling.
PA/ST/QL/AL/DF/LDD meanings: Drugs listed with 'PA' require prior authorization; 'ST' indicates step therapy; 'QL' indicates quantity limits; 'AL' indicates age limits; 'DF' indicates Dental Formulary only; 'LDD' indicates limited distribution drugs via designated specialty pharmacies.
Prior Authorization: Medicines requiring prior authorization must have a request submitted by the prescriber and approved by Independent Health prior to coverage.
Step Therapy: Where 'ST' applies, members must trial required step medications before coverage of the next-line agent; prior authorization may document steps tried.
Compounding rules: Compounded prescriptions must be prepared by a participating pharmacy, contain at least one prescription component, and be submitted for prior approval. Compounds costing under $200 do not require prior authorization if all other requirements are met; compounds > $200 require prior authorization. Bulk products and powders are excluded.
OTC/COVID test limits: Only FDA-approved OTC COVID-19 tests (including EUA) administered and read by the member without a doctor's order are covered. Each member may get up to eight (8) OTC tests in a 30-day period (typically four 2-test kits per 30 days).
Diabetic supply rules: Coverage for diabetic supplies depends on plan; preferred products include FreeStyle meters and supplies (no prior authorization). One FreeStyle meter per member per plan year. Embecta needles/syringes are preferred; other sizes may require prior authorization. Alcohol swabs are covered.
Diabetic test strip limits: Non-insulin dependent diabetics: maximum 100 test strips per 30 days. Insulin dependent diabetics: maximum 300 test strips per 30 days.
Continuous glucose monitor rules: FreeStyle Libre (Libre, Libre 2, Libre 3) sensors available at retail without prior authorization for members using short- or rapid-acting insulin multiple times daily. Fill limits: up to 2 sensors per 28-day supply (or 6 sensors per 84-day supply) and one receiver per plan year. Dexcom G6/G7 are non-preferred and require prior authorization; if approved, up to 3 sensors per 30 days, one G6 transmitter every 90 days (G7 includes transmitter), and one receiver per plan year.
Opioid limits: Opioid medications limited to a maximum of four (4) fills per 30 days.
Excluded categories: Appetite suppressants/weight-loss medications, medications for cosmetic purposes, most medical foods (except for inborn errors of metabolism such as PKU), prenatal vitamins classified as medical foods, medications for sexual/erectile dysfunction, fertility-promoting medications for Child Health Plus, growth hormones for short stature, and any medicine excluded under state/federal law are not covered.
Medical necessity and off-label use: Drugs must be for medically-accepted indications based on FDA labeling and applicable guidelines; drugs listed as covered without restriction may still require prior authorization or be denied if used for non-FDA-approved indications or treatments not covered under the member's contract.
Prescription medicines not approved by the FDA or without an NDC are excluded from coverage.
Vacation/Replacement supplies: Replacement of lost, stolen, or damaged medications is member responsibility; vacation supplies and early refills via prior authorization are not allowed for lost/stolen/damaged medications.
Dental prescribing: Medicines covered on the Dental Formulary are available when prescribed by a dental provider; medications without 'DF' will not be covered when written by a dental provider.
Limited distribution drugs: Specialty medicines with manufacturer limited distribution require dispensing via designated specialty pharmacies as listed and are marked LDD.
Generic substitution note: Generic substitution is used only as required by state pharmacy laws; therapeutic interchange is not utilized.

Key thresholds / limits

OTC COVID-19 test limitUp to 8 OTC tests per 30 days (typically 4 two-test kits)

Diabetic test strips - non-insulinMaximum 100 strips per 30 days

Diabetic test strips - insulin dependentMaximum 300 strips per 30 days

FreeStyle Libre sensorsUp to 2 sensors per 28 days (or 6 per 84 days); 1 receiver per plan year; no prior auth for eligible insulin users

Dexcom G6/G7 sensorsNon-preferred; require prior authorization; up to 3 sensors per 30 days; 1 G6 transmitter every 90 days; 1 receiver per plan year

Opioid fill limitMaximum 4 fills per 30 days

Formulary Flags & Definitions

Prior Authorization / Step Therapy / Quantity / Age / Other Flags

Formulary uses flags to denote requirements and limits (applies per-line on formulary drug list):

Formulary Flags / Key

PA flag = Prior Authorization Required
Requires provider submission and approval prior to coverage
ST flag = Step Therapy Required
Requires trial and failure or contraindication of required step agents
QL flag = Quantity Limits Apply
Limits are often per 30 days and may override package size
AL flag = Age Limit

Provider Actions & Operational Requirements

Prior Authorization

Submit Prior Authorization for PA-flagged drugs

Providers must submit prior authorization requests for medicines listed with 'PA'. Prior authorization requests (including medical exception requests for non‑formulary medications) must be submitted by the prescribing provider and approved by Independent Health before coverage will be provided.

PA flag on the formulary indicates prior authorization is required.
Medical exception form required for non‑formulary coverage; fax to Independent Health's Prior Authorization Department.

Step Therapy

Follow Step Therapy for ST-flagged drugs

When a drug line is flagged 'ST', providers must document that required step agents were tried and either failed or were contraindicated before the requested agent will be authorized.

ST flag = Step Therapy Required.
Documentation of trial and failure or contraindication of required agents must be provided.

Listing-specific Notes & Examples

Part 1 of the formulary contains many therapeutic-class listings with mixed tiering and flags. Specific examples called out in the brief include TOBI PODHALER, ABRILADA, leflunomide, fentanyl patches, tobramycin, and FreeStyle/Dexcom device/supply rules. Flags (PA, ST, QL, AL, DF, LDD) vary by formulation and line — e.g., inhaled vs. injectable vs. oral forms may carry different requirements. Consult the full formulary Part 1 for per-line details and the exact flag/tier assignments for each formulation.

Formulary Flags / Keymixed

AL	Age Limit
DF	Dental Formulary
LDD	Limited Distribution Drugs
PA	Prior Authorization Required
QL	Quantity Limits Apply
ST	Step Therapy

Sample Drug EntriesmixedCovered

TOBI PODHALER	inhaled tobramycin product — example listing; flags vary by formulation/line
ABRILADA	biologic example called out in brief; refer to specialty rules
leflunomide	oral immunomodulator — example of therapeutic-class listing
fentanyl patches	transdermal opioid examples; opioid fill limits apply
tobramycin	aminoglycoside class examples; inhaled vs systemic lines differ
FreeStyle Libre / Dexcom	CGM device/sensor rules; FreeStyle preferred, Dexcom G6/G7 require PA

Drugs with explicit PA notemixedCovered

Dexcom G6	requires prior authorization for Child Health Plus members (non-preferred)
Dexcom G7	requires prior authorization for Child Health Plus members (non-preferred)

Drugs with QL or AL notesmixedCovered

opioids	limited to maximum of four fills per 30 days
aprepitant	example of a drug with quantity limitation

Drugs with Step Therapy notesmixedCovered

Step Therapy (ST)

Applied where members must try preferred/step agents first

Selected anticoagulants / injectablesmixedCovered

selected injectables

some specialty injectables may be LDD or require PA

Formulary entries (expanded sample list - ensure per-line checks)mixedCovered

paroxetine hcl er oral tablet	extended-release SSRI (per-line rules may vary)
INJECTOR 4 MG/3ML	example injectable product code — check specialty handling
acarbose oral tablet	antidiabetic alpha-glucosidase inhibitor
OZEMPIC (2 MG/DOSE)	semaglutide injectable dose — check formulary line and PA
ADMELOG INJECTION SOLUTION	insulin analog — coverage per insulin rules
ADMELOG SOLOSTAR	prefilled insulin pen device
pioglitazone hcl-metformin hcl oral	combination oral antidiabetic agent
BAQSIMI ONE PACK NASAL	glucagon nasal rescue product
repaglinide oral tablet	meglitinide antidiabetic
SEGLUROMET ORAL TABLET	combination diabetic agent

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Unproven / Exclusions

Exclusions and coverage limits stated in Part 1: appetite suppressants/weight‑loss medications and medications used for cosmetic purposes are excluded from coverage.

Most medical foods are excluded except when used to treat inborn errors of metabolism (for example PKU); prenatal vitamins that are classified as medical foods are not covered.

Medications for sexual/erectile dysfunction and any medicines used to promote fertility are not covered for Child Health Plus members; growth hormones prescribed for short stature are excluded.

The formulary excludes medicines not FDA‑recognized with a National Drug Code (NDC) or not FDA‑approved, and drugs found less effective by the FDA DESI process. Note: medicines listed as covered may still require prior authorization if used for non‑FDA indications or in conjunction with non‑covered procedures.

Applicable Codes / Formulary Flags

Formulary Flags / Keymixed

PA	Prior Authorization Required
ST	Step Therapy Required
QL	Quantity Limits Apply
AL	Age Limit
DF	Dental Formulary
LDD	Limited Distribution Drug

Sample Drug Entries (therapeutic class)NDC|drug_nameCovered

ADDERALL ORAL TABLET 10 MG	amphetamine/dextroamphetamine oral tablet (ADHD class)
TOBI PODHALER INHALATION CAPSULE	tobramycin inhalation product - Notes: PA; QL; cystic fibrosis specialist exception
celecoxib oral capsule	NSAID (Analgesics - Anti-Inflammatory)
methylphenidate hcl er (osm) oral tablet 18 mg,27 mg,36 mg,54 mg	ADHD extended-release formulations listed
enoxaparin sodium injection	Anticoagulant injectable - Tier = 1 entries present

PA-flagged drugs (examples)NDC|drug_nameCovered

FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR	Notes = PA
FRAGMIN SUBCUTANEOUS	Notes = PA; appears multiple times
diazepam rectal gel	Notes = PA; PA except specialty noted
carbamazepine er oral tablet	Notes = PA; PA except; neurology; QL; AL
tramadol-acetaminophen oral tablet	Notes = PA; PA except Pain Medicine

Systems and examplesmixed

Diabetic supply rules	FreeStyle preferred supplies; test strip limits: 100/30 non-insulin, 300/30 insulin; FreeStyle Libre sensors limits and Dexcom PA requirements
Compounded prescriptions	Compounds < $200 do not require PA if requirements met; > $200 require PA
OTC COVID tests	Up to 8 OTC tests per 30 days (approx. 4 kits if 2 per kit)

Notes on utilization managementmixed

Opioid fills limit	Maximum of 4 fills per 30 days
Exclusions	Excluded categories include appetite suppressants, cosmetic meds, fertility meds for Child Health Plus, growth hormones for short stature, and others

Representative coding/systemmixed

NDC/drug_name

Most drug examples and line entries use drug name and NDC where provided; tiers and notes shown per-line in formulary

Reference and revisionmixed

Revised October 2025

Header indicates 'Revised October 2025'

Clinical Evidence & Notes

Evidence: No formal clinical trial evidence or trial metrics are provided within Part 1. The part includes policy language that coverage is limited to medically accepted indications based on FDA labeling and clinical guidelines where applicable.

Some utilization exceptions or specialist exceptions reference care by clinical specialists (for example PA exceptions for cystic fibrosis specialists for certain inhaled aminoglycosides), but Part 1 does not present supporting trial data — it references clinical specialty practice and FDA labeling as the basis for medically‑accepted indications.

Background

Background and design intent: Independent Health maintains a two‑tier Child Health Plus formulary with Tier 1 primarily generics and Tier 2 primarily brand-name and specialty products to promote safe, effective and cost‑conscious prescribing.

The formulary is aligned with New York State Child Health Plus program rules and implements per-line utilization management (PA, ST, QL, AL, LDD, DF) and administrative rules (compounding thresholds, OTC coverage, diabetic supply limits).

This document is Part 1 of 9 and contains the introductory sections, key definitions, general coverage exclusions and the beginning of the therapeutic‑class drug listings and sample drug entries.

Revision History

2025-10-01document noteLatest

Revised October 2025 indicated on document; no specific material clinical policy changes documented in Part 1.

OpenPayer

Independent Health 2026 Child Health Plus Formulary (Part 1)