CurrentIndependent HealthPolicy N/A

Independent Health 2026 Drug Formulary II (Part 1)

Defines covered prescription drugs, tiers (1-3), and formulary rules including prior authorization, step therapy, quantity limits, specialty pharmacy, limited distribution, ACA/preventive indicators, age limits, 90-day maintenance supply, compounding rules, diabetic supplies, and exclusions for Independent Health's Drug Formulary II used for NY State of Health marketplace and individual plans.

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2026 Drug Formulary II (Part 1)

Policy CodePolicy N/A

Change TypeRevised (Jan 2026) — no material change

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit prior authorization/medical exception forms to Independent Health's Prior Authorization Department for drugs marked 'PA' and follow step therapy, quantity limit and specialty dispensing requirements as noted on the formulary.

SourceLink

POLICY UPDATE CHANGES

Revised January 2026 (document footer indicates revision date).

3Formulary Tiers

multipleManagement Flags (PA/ST/QL/SP/LDD/MM/etc.)

100+Therapeutic Categories Listed

manyEntries with PA noted

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Diabetic supply thresholds

Coverage Summary & Formulary Scope

Independent Health Drug Formulary II is the plan's official, 3‑tier prescription drug list used for plans offered through the NY State of Health marketplace and for Independent Health individual plans. It is intended to balance effectiveness, safety and cost by providing options across Tier 1 (lowest cost-share), Tier 2, and Tier 3 (highest cost-share). Covered product types include prescription drugs (generic, brand, biologic and specialty agents) and selected diabetic supplies (meters, lancets, test strips, CGM sensors/transmitters/receivers) per plan rules. Major exclusions and limits called out include: non‑FDA‑recognized products or drugs without an NDC, prescription medications not approved by the FDA, drugs found by DESI to be less than effective, most medical devices (except listed diabetic supplies and inhaler spacers), and medical foods other than for inborn errors of metabolism.

Coverage Conditions and Formulary Management

Coverage and access depend on plan association, formulary tier, and additional management flags (PA, ST, QL, SP, LDD, ACA, PV, AL, MM, OTC, DF); compounding and exclusions described below.

Plan association and tiers: Member's plan must be associated with Drug Formulary II (check summary of benefits).
Tiered cost-sharing: Drugs listed on the formulary are subject to tiered cost-sharing: Tier 1 (lowest), Tier 2, Tier 3 (highest).
Prior authorization (PA): Prior authorization required for medications marked 'PA' on the formulary; provider must submit prior authorization/medical exception to Independent Health Prior Authorization Department.
Step therapy (ST): Step therapy required for medications marked 'ST' on the formulary; member must try required medication(s) first.
Quantity limits (QL): Quantity limitations apply for medications marked 'QL' and are expressed as specific quantities per 30- or 90-day supply when designated.
Specialty pharmacy (SP): Specialty medications (marked 'SP') may be limited to designated specialty pharmacy (Reliance Rx) and may require special distribution/handling; Reliance Rx contact provided.
Limited distribution drugs (LDD): Limited Distribution Drugs (marked 'LDD') must be obtained through designated specialty pharmacies.
ACA / Preventive (ACA / PV): ACA preventive medications (marked 'ACA') and certain preventive medications for qualifying chronic conditions (marked 'PV') have no member cost-sharing if applicable per member contract and plan.
Age limits (AL): Age restrictions (marked 'AL') apply per FDA labeling; may not be fully listed on formulary but still apply.
Maintenance 90-day supply (MM): Maintenance medications eligible for up to a 90-day supply are indicated with 'MM'.
OTC with prescription (OTC): Certain over-the-counter products are covered only with a prescription (marked 'OTC').
Dental formulary (DF): Medications covered on the Dental Formulary are available when prescribed by a dental provider and listed with 'DF'; medications without 'DF' will not be covered when written by a dental provider.
Compounded prescriptions must be prepared by a participating pharmacy, contain at least one prescription component, and the dispensing pharmacy must submit for prior approval; compounded prescriptions covered at Tier 2 when approved; compounds under $200 do not require prior authorization if other requirements are met; bulk products and powders excluded from coverage.Compounded prescription cost threshold: > $200 requires prior authorization
Other exclusions and rules: Medications used for cosmetic purposes, most medical devices (except listed diabetic supplies and inhaler spacers), medical foods (except for inborn errors of metabolism), medications without an NDC or not FDA-recognized, prescription medications not FDA-approved, and DESI drugs found less effective are excluded; generic substitution per state law applies and therapeutic interchange is not utilized.
Formulary changes generally take effect at plan renewal; removal for safety (FDA/manufacturer) is immediate and communicated per notification requirements.

Formulary management flags summary: Formulary uses flags/abbreviations (PA, ST, QL, SP, LDD, ACA, PV, AL, MM, OTC, DF) to indicate utilization controls and coverage attributes; providers must follow the plan's prior authorization and specialty pharmacy processes where notes apply.

Medical Exception / Non-Formulary Requests

Covered when ALL of the following are met:

Medical exception submission: Provider completes medical exception form and submits to Independent Health's Prior Authorization Department.
Medical Director approval: Independent Health Medical Director must approve the medical exception.
Cost-sharing if approved: If approved, the non-formulary drug will be covered at Tier 3 member cost-sharing.Tier 3 cost-sharing applies

Prior authorization note: Medications that require prior authorization are listed with 'PA' on the formulary and require a PA request submitted by the health care provider and approved by Independent Health.

Diabetic Supplies — Coverage Rules & Limits

Diabetic Supplies Coverage Rules

Coverage and limits for diabetic supplies (all requirements must be met):

Plan-dependent coverage: Covered products depend on plan; products not listed require prior authorization.
Preferred needles/syringes: Embecta needles and syringes are preferred; typical insulin sizes covered; other sizes require prior authorization.
Alcohol swabs to prep for using diabetic medicines are covered.
Preferred meters and supplies: FreeStyle glucose meters, lancets, test strips, and supplies are preferred and do not require prior authorization; Abbott provides one glucose meter per member with no member cost-sharing (limited to one meter per member).

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization Required

Obtain prior authorization for PA‑marked drugs. Submit a prior authorization or medical exception request to Independent Health's Prior Authorization Department. Medical Director approval is required for medical exceptions.

Submit PA/medical exception requests to Independent Health Prior Authorization Department.
Medical Director review and approval required for medical exceptions.

Step Therapy

Step Therapy Applies

Follow step therapy requirements for ST‑marked drugs. Ensure the required trial(s) of first‑line medications per the plan's step edits are documented before requesting coverage for later‑line agents.

Providers must document trials of required first‑line medications as specified by step edits.
Step therapy applies where 'ST' appears on formulary entries.

Formulary Management Flags & Sample Product Indicators

Formulary management indicators / flags used in the drug listmixed

PA	Prior Authorization Required
ST	Step Therapy Required
QL	Quantity Limit Applies
SP	Specialty Pharmacy (Reliance Rx)
LDD	Limited Distribution Drug
ACA	Affordable Care Act Preventive Service
PV	Preventive (no member cost-sharing for qualifying plans)
AL	Age Restriction Applies
MM	Eligible for 90-day Maintenance Supply
OTC	Over-the-Counter product covered with prescription

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Sample drugs and attributes (excerpt)mixed

ARIKAYCE	Inhaled antibacterial — specialty/limited distribution considerations
IMCIVREE	Rare disease therapy — specialty, PA likely
REPATHA SUBCUTANEOUS	PCSK9 inhibitor — specialty, PA and QL may apply
FreeStyle Libre / Dexcom G6 / Dexcom G7	Continuous glucose monitoring systems — device/sensor coverage rules, MM/OTC notes; sensor quantity limits apply per policy
OTEZLA ORAL TABLET	PDE4 inhibitor — may have ST or PA for certain indications; XR/pack/initiation considerations
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE / ORENCIA CLICKJECT	Biologic for RA — specialty, PA required; ClickJect and auto-injector presentations noted (375 mg, 500 mg listed for extended-release formats where applicable)
KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR	IL-6 receptor antagonist — specialty, PA likely; auto-injector presentation
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER	Methylphenidate extended-release suspension — behavioral health product, QL/MM may apply
SUNOSI ORAL TABLET	Wakefulness-promoting agent — PA/ST may apply
GRASTEK SUBLINGUAL TABLET SUBLINGUAL	Allergen immunotherapy SL tablet — PA or age restrictions may apply

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Definitions / Key Terms

PA — Prior Authorization Required: medication listed with 'PA' requires a prior authorization request submitted by the provider and approval by Independent Health.

ST — Step Therapy: 'ST' indicates required trial(s) of preferred/first‑line medication(s) before the requested agent will be covered.

QL — Quantity Limits Apply: 'QL' indicates a specific quantity or duration restriction (per 30‑ or 90‑day supply) applies.

SP — Specialty Pharmacy: 'SP' indicates specialty medications that may be dispensed through designated specialty pharmacies (e.g., Reliance Rx).

LDD — Limited Distribution Drugs: 'LDD' indicates drugs available only through manufacturer‑designated specialty channels.

ACA — Affordable Care Act preventive: 'ACA' flags drugs covered as ACA preventive services with no member cost‑sharing where applicable.

PV — Preventive (no member cost‑share for qualifying chronic conditions): 'PV' marks preventive meds covered without cost‑share for qualifying plans.

AL — Age Limit: 'AL' indicates age restrictions per FDA labeling that apply to coverage.

MM — Maintenance / 90‑day supply eligible / Medical Management: 'MM' flags maintenance or medical management review and identifies medications eligible for 90‑day fills when noted.

OTC — Over‑The‑Counter (covered with prescription): 'OTC' indicates OTC products covered only with a prescription.

DF — Dental Formulary: 'DF' indicates medications covered when prescribed by a dental provider; without 'DF' dental prescriptions are not covered.

Background & Scope Notes

Independent Health's Drug Formulary II is designed to provide clinically appropriate options while managing cost and safety; the formulary uses utilization controls (specialty distribution, prior authorization, step therapy and quantity limits) to implement coverage rules rather than to provide therapeutic guidance.

Formulary delivery includes specialty pharmacy distribution (Reliance Rx for complex/specialty agents) and plan-specific management flags (PA, ST, QL, SP, LDD, MM).

The formulary specifically defines diabetic supplies rules (preferred FreeStyle and Abbott meter program, test strip limits, and CGM sensor/transmitter/receiver supply limits) and describes compounded medication requirements (compounds prepared by participating pharmacies, prior approval when cost > $200, excluded bulk products/powders).

Some product coverage and limits depend on the member's plan association with Drug Formulary II and on the member contract (e.g., ACA/PV provisions and insulin cost‑share), and this extract represents Part 1 of the 2026 formulary (revised January 2026).

Clinical Evidence & Usage Notes

This extract does not include clinical trial citations or therapeutic evidence references. The document indicates prior authorization, step therapy and other utilization controls are programmatic coverage requirements (e.g., 'PA', 'ST', 'QL') and reflect formulary management and benefit administration rather than direct clinical guidance. For medical necessity or clinical evidence inquiries providers should submit prior authorization or medical exception requests as described in the formulary.

Document Revisions

2026-01revisedLatest

Revised January 2026 (document footer indicates revision date). Noted revision is non-material to clinical policy statements per Part 1; change text: Revised January 2026 (document footer indicates revision date).

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2026 Drug Formulary II (Part 1)

Policy CodePolicy N/A

Change TypeRevised (Jan 2026) — no material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

One meter per member

Abbott offer code and contact provided in formulary

Test strip quantity limits: Diabetic test strips limit: non-insulin dependent diabetics: max 100 per 30 days; insulin dependent diabetics: max 300 per 30 days.<=100 per 30 days (non-insulin); <=300 per 30 days (insulin)

CGM supplies and limits: Continuous glucose monitors/sensors (FreeStyle Libre series, Dexcom G6/G7) available at retail pharmacies without prior authorization for members using short or rapid-acting insulin multiple times daily; specific fill and device limits apply: FreeStyle Libre sensors up to 2 sensors per 28-day supply (or 6 per 84-day) and one receiver per plan year; Dexcom G6/G7 up to 3 sensors per 30-day supply (or 9 per 90-day), one wireless transmitter every 90 days (G7 includes built-in transmitter), and one receiver device per plan year.FreeStyle Libre: up to 2 sensors/28-day (6/84-day); Dexcom: up to 3 sensors/30-day (9/90-day); transmitter/receiver limits as noted

Retail pharmacy availability without PA for eligible insulin users

Prior authorization for unlisted products: Products not listed in the diabetic supplies section require prior authorization per plan rules.

Surface thresholds

Diabetic test strips (non-insulin dependent)Maximum 100 strips per 30 days

Diabetic test strips (insulin dependent)Maximum 300 strips 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 has built-in transmitter); one receiver per plan year

FreeStyle Libre receiversOne receiver allowed per plan year

Dexcom receiverOne receiver device allowed per plan year

Compounded prescriptions cost thresholdCompounds costing more than $200 require prior authorization; compounds under $200 do not require prior authorization if other requirements met

Billing Rule

Compounded Prescriptions — PA & Tiering

Compounded prescriptions prior approval and tiering. Participating dispensing pharmacies must submit for prior approval for compounded medications costing more than $200; compounds that meet coverage requirements and are approved will be reimbursed at Tier 2.

Compounds under $200 do not require prior authorization if all other requirements are met.
Compounds over $200 require prior authorization.
Bulk products and powders are excluded from coverage.

Documentation Required

Specialty / Limited Distribution / Attestation

Specialty pharmacy, limited distribution, and attestation requirements. Specialty (SP) and limited distribution (LDD) flags indicate additional medical management or designated pharmacy routing. Where specialty distribution is required, Reliance Rx is the designated specialty pharmacy and may manage distribution, patient education, and home delivery. Some biologics and specialty agents require an attestation or additional certification prior to coverage and/or must be obtained through a limited distribution channel.

Reliance Rx is the specialty pharmacy contact for designated SP drugs (1-800-809-4763).
Limited distribution drugs (LDD) must be obtained through the manufacturer‑designated pharmacy.
Selected biologics require provider attestation; follow the formulary note for attestation and routing instructions.

Billing Rule

Attestation & Distribution Routing

Attestation and distribution routing for select products. Certain specialty or brand products require provider attestation and/or routing through designated specialty distributors (including Reliance Rx) to be eligible for coverage; follow the formulary notes for product‑specific routing.

Provider attestation may be required for select biologics and specialty agents prior to prior authorization approval.
When limited distribution applies, prescriptions must be filled at the designated specialty pharmacy as noted on the formulary (e.g., Reliance Rx).

Billing Rule

Quantity & Duration Limits; Diabetic Supplies

Quantity and duration limits; diabetic supply procurement. Quantity limits (QL) and duration limits apply to many drugs — providers must monitor QL flags and request prior authorization when exceeding limits. Examples include anticoagulant courses greater than 14 days requiring PA, and diabetic supply limits for meters, test strips, sensors, and transmitters as noted below.

Anticoagulant courses >14 days: prior authorization may be required as indicated on the formulary.
Diabetic test strips: up to 100 per 30 days for non‑insulin users; up to 300 per 30 days for insulin users.
One glucose meter per member program year supplied by Abbott (FreeStyle) — contact Abbott for fulfillment (1-800-680-6850, offer code DOVL6F17).
CGM sensors: FreeStyle sensors—up to two sensors per 28 days (or six per 84 days); Dexcom G6/G7—up to three sensors per 30 days (or nine per 90 days) and transmitter/receiver limits as specified.
Quantity limits noted on formulary entries take precedence over prepackaged counts when applicable.

Documentation Required

Utilization Controls Summary

Consolidated utilization‑control summary. The formulary uses utilization flags to indicate controls and required provider actions. When you see these flags on formulary entries, follow the plan's PA/step therapy and specialty processes.

Common flags: PA (Prior Authorization), ST (Step Therapy), MM (Maintenance/90‑day), SP (Specialty Pharmacy), LDD (Limited Distribution Drug), QL (Quantity Limits), AL (Age Limits), PV (Preventive), ACA (ACA Preventive), OTC (Over‑the‑Counter), DF (Dental Formulary), SUD (Substance Use Disorder controls), PV (Preventive).
Follow plan‑specific prior authorization and step therapy procedures whenever these flags appear on formulary entries.
Specialty, limited distribution, attestation, quantity and duration limits must be addressed per the formulary notes to avoid claim denials.

Documentation Required

HIV Post‑Exposure Prophylaxis Documentation

Document diagnosis for HIV post‑exposure prophylaxis (PEP). Coverage for PEP medications requires documentation of the diagnosis or exposure circumstances in the medical record.

Medications for HIV post‑exposure prophylaxis are covered when a diagnosis is documented.

SUD — Substance Use Disorder flag: 'SUD' annotates products related to substance use disorder programs or coverage rules.