Independent Health Drug Formulary II Coverage & PA

Coverage Summary

Independent Health maintains an independent drug formulary that selects drugs for safety and effectiveness and organizes covered products into a 3‑tier structure (Tier 1 = lowest cost‑share, Tier 2 = moderate cost‑share, Tier 3 = highest cost‑share). The formulary applies to plans sold through the NY State of Health marketplace and to Independent Health individual plans sold directly; members should confirm this Drug Formulary II is associated with their plan in their summary of benefits.

Certain categories are explicitly excluded or limited from coverage: medications used for cosmetic purposes, non‑FDA–approved medications and drugs without an NDC, most medical devices (only specified diabetic supplies and inhaler spacers are covered), and bulk products/powders for compounding are excluded.

General Formulary Coverage Criteria

Formulary coverage, restrictions and special program designations:

Formulary selection and tiers: Drugs listed on the formulary are chosen for effectiveness and safety and are covered according to tier and plan benefit.
Prior authorization (PA) is required for medications listed with 'PA' and must be requested by the provider and approved by Independent Health.
Providers must submit prior authorization requests for medications marked 'PA'.
Step therapy (ST) applies when listed with 'ST' and requires trying specified medications first per the formulary's step therapy rules.
Quantity limits (QL) apply when listed and limit quantities per 30- or 90-day supply; QL designation takes precedence over prepackaged limits when applicable.
Specialty (SP) and limited distribution (LDD): Specialty medications (SP) and limited distribution drugs (LDD) are identified and may require filling at designated specialty pharmacies (e.g., Reliance Rx) and may have special handling/distribution requirements.
Reliance Rx contact and specialty program described in formulary.
Compounded prescriptions must be prepared by a participating pharmacy, contain at least one prescription component, and require prior authorization if cost > $200; compounds under $200 do not require prior authorization if other requirements are met; bulk products and powders are excluded.$200
Coverage per Compounding Medication Products Policy.
ACA preventive (ACA) and preventive (PV): Medications listed 'ACA' are ACA preventive services with no member cost-sharing when applicable; medications listed 'PV' are preventive for qualifying chronic conditions and have no member cost-sharing when applicable and when the member's plan includes that benefit.
Refer to member contract for applicability.
Age limits (AL): Age restrictions indicated with 'AL' apply; FDA labeling age limits apply even if not listed on the formulary.
Maintenance medications (MM): Medications eligible for maintenance 90-day fills are indicated with 'MM'.90-day
Over-the-counter (OTC): OTC products listed require a prescription for coverage and are designated 'OTC'.
Dental formulary (DF): Medications on the Dental Formulary are indicated 'DF' and are covered only when prescribed by a dental provider.
Exclusions and non-covered items: Medications used for cosmetic purposes, most medical devices (except specified diabetic supplies and spacers), medical foods (except for inborn errors of metabolism), non‑FDA‑approved medications, medications without an NDC, and drugs found less than effective under DESI are excluded from coverage.

Diabetic Supplies and Continuous Glucose Monitors

Quantity limits / device limits

Diabetic Test Strips (non‑insulin dependent)<= 100 per 30 days

Diabetic Test Strips (insulin dependent)<= 300 per 30 days

FreeStyle Libre sensors<= 2 sensors per 28 days or <= 6 per 84 days; one receiver per plan year

Dexcom sensors<= 3 sensors per 30 days or <= 9 per 90 days; one wireless transmitter every 90 days; one receiver per plan year

Dexcom transmitter noteDexcom G7 sensors include built‑in transmitter

Medical Exception / Non-Formulary Coverage

Process to cover non-formulary drugs:

Submit medical exception: If a medicine is not on the formulary and the provider deems it medically necessary, the provider must complete a medical exception form and fax it to Independent Health's Prior Authorization Department for review by the Medical Director.
Fax to Prior Authorization Department per provider actions guidance.
If approved — coverage and cost-sharing: If the medical exception request is approved, the non‑formulary drug will be covered at Tier 3 member cost‑sharing.Tier 3

Providers may request a medical exception by completing the medical exception form and faxing it to Independent Health's Prior Authorization Department; if the request is approved the non‑formulary medication is covered at Tier 3 cost‑sharing. The brief and provider actions note faxing the completed medical exception form to the Prior Authorization Department as the contact path for exception requests.

Provider Actions & Operational Requirements

Billing Rule

Bill using the applicable NDC or J-code and follow formulary mapping and PA rules. Use the mapped drug name when submitting claims; mapped names and formulary mappings can affect PA, step edits, quantity limits, and specialty pharmacy handling.

Formulary Tiers, Flags & Designations

Formulary Tiers (Tier 1 / Tier 2 / Tier 3)mixed

Tier 1	Lowest member cost-share — preferred generics and selected brands.
Tier 2	Intermediate member cost-share — commonly used brand drugs and select generics.
Tier 3	Highest member cost-share — non-preferred brands, specialty, or high-cost agents.
phenytoin oral suspension	Included and mapped to appropriate tier per product-specific formulary row.
phenytoin oral tablet chewable	Included and mapped to appropriate tier per product-specific formulary row.
pregabalin oral capsule	Included and mapped to appropriate tier per product-specific formulary row.
DIACOMIT ORAL CAPSULE / PACKET	Included and mapped to appropriate tier per product-specific formulary row.
topiramate er oral capsule er 24 / oral capsule / oral tablet / er 24 hour	All formulations listed and mapped to tiers on product rows.
valproic acid oral capsule	Included and mapped to appropriate tier per product-specific formulary row.
VALTOCO nasal (5/10/15/20 mg dose nasal)	Nasal rescue formulation included and tiered on formulary.

1–10 of 15

1/2

Designations / Formulary Flagsmixed

PA	Prior Authorization required for specific product/indication per product row.
ST	Step Therapy — try preferred agent(s) first as specified on product row.
QL	Quantity Limits — limits apply per time period as specified.
SP	Specialty Pharmacy required — may be filled through designated specialty vendor.
LDD	Limited Distribution Drug — available only through specified distributor(s).
MM	Maintenance Medication — eligible for up to 90-day supply where applicable.
AL	Age Limit — use restricted to specified age ranges per labeling.
ACA	ACA preventive service — no member cost-sharing if eligible and plan applies.
PV	Preventive — no member cost-sharing when criteria met and plan applies.
OTC	Over-the-Counter product — prescription required for coverage.

1–10 of 41

1/5

The formulary rows map many specific drug and formulation variants (for example different strengths, injectable vs oral, extended-release vs immediate-release, nasal rescue products, and pack sizes) to the three tiers and to the flags listed above. Providers must consult the product-specific formulary row for the exact tier, and for detailed Prior Authorization (PA), Quantity Limit (QL), Limited Distribution (LDD) and Step Therapy (ST) requirements, as summarized in the policy scope and examples in the formulary entries.

Sample Formulary Entries / Notable Products

Illustrative high‑impact examples from the extracted rows include: QUILLIVANT XR and other ADHD/anorexiant entries listed (often Tier 3 with ST/PA flags), CONTRAVE listed with PA/Tier 3, multiple GVOKE presentations (hyropen/kits vs PFS where GVOKE PFS may be PA/SP), many insulin products and pen/cartridge presentations (HUMALOG, HUMULIN, LANTUS, TOUJEO, TRESIBA, and references to OZEMPIC/MOUNJARO/TRULICITY pens) with I/MM/QL/ST annotations, and numerous oncology and specialty biologic agents flagged with PA/SP/LDD (e.g., many antineoplastics, REPATHA, JUXTAPID, FERRIPROX). This is a sampling; the full formulary listing continues in the source document.

Background & Definitions

Formulary selection is intended to promote safety and effectiveness; the program uses utilization management tools including Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), Specialty Pharmacy (SP) and Limited Distribution Drug (LDD) channels, plus a 90‑day maintenance (MM) supply option where indicated. The formulary applies to NY State of Health marketplace individual plans and Independent Health individual plans; members should check their member contract and summary of benefits for plan‑specific tier/copay and insulin or diabetic supply cost‑share details.

Formulary abbreviations / definitionsmixed

PA	Prior Authorization Required
ST	Step Therapy
QL	Quantity Limits Apply
SP	Specialty Pharmacy
LDD	Limited Distribution Drugs
MM	90-day maintenance supply eligible
AL	Age Limit
ACA	Affordable Care Act preventive medication
PV	Preventive (no member cost-share when applicable)
OTC	Over-the-Counter (requires prescription for coverage)

1–10 of 13

1/2

Evidence & Document Scope

This document is a formulary listing (a policy fragment) and contains limited clinical evidence entries (the brief's evidence[] is empty). Document status is CURRENT; last review date: 2026‑01‑01.

Policy metadata

Policy TitleIndependent Health 2026 Drug Formulary II (Part 1)

StatusCURRENT

Last review2026-01-01

Next review

PartPart 1 (introductory pages and beginning of formulary)

Revision History

2026-01-01Last reviewLatest

Formulary reviewed; part 1 extract updated