ModifiedIndependent HealthPolicy N/A

Purixan_Ridaura_Formulary_Changes_and_Coverage_Determination_Request

Notifies formulary deletions for two oral suspension/capsule products from Independent Health's Pharmacy Benefit Dimensions PDP 5 Tier formulary, provides effective date, suggested alternatives, reasons, and instructions for requesting coverage determinations or exceptions.

Policy Summary

PayerIndependent Health

PolicyPurixan_Ridaura_Formulary_Changes_and_Coverage_Determination_Request

Policy CodePolicy N/A

Change TypeFormulary deletions (2 products)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProvide a supporting statement showing medical necessity for non-formulary or exception requests and submit requests via mail, fax, or phone to the Pharmacy Department (expedited decision within 24 hours; standard within 72 hours).

SourceLink

POLICY UPDATE CHANGES

Purixan 20 mg/mL oral suspension removed from Pharmacy Benefit Dimensions PDP 5 Tier formulary.

Ridaura 3 mg capsules removed from Pharmacy Benefit Dimensions PDP 5 Tier formulary.

2Formulary Deletions Announced

6/1/2025Effective Date

24/72Decision Timeframes (hrs)

Summary of Formulary Changes

Independent Health updated its Pharmacy Benefit Dimensions PDP 5 Tier formulary to delete branded products where generic alternatives exist. The bulletin lists each deleted product, the recommended generic alternative, the rationale for deletion, and the effective date of 6/1/2025.

Key facts

Effective date2025-06-01

Number of formulary deletions2

Scope summaryNotifies formulary deletions for two oral suspension/capsule products from Independent Health's Pharmacy Benefit Dimensions PDP 5 Tier formulary, provides effective date, suggested alternatives, reasons, and instructions for requesting coverage determinations or exceptions.

Coverage stancemixed

Formulary Change Conditions

Formulary deletions effective on specified date with listed alternatives and reason

ANY of the following

Purixan 20 mg/mL oral suspension — Type of Change = Formulary Deletion
Alternative = mercaptopurine 2 mg/mL oral suspension; Reason = Generic Alternative on TS; Effective = 2025-06-01
Ridaura capsule 3 mg — Type of Change = Formulary Deletion
Alternative = auranofin 3 mg capsule; Reason = Generic Alternative on TS; Effective = 2025-06-01

Coverage Determination & Exception Requests — What Providers Must Do

Coverage Determination / Exception Requests

Requests for coverage determination or exception must meet supporting statement requirements and follow timing rules

ALL of the following

Request may be submitted via mail, fax, or phone to Independent Health's Pharmacy Department
Mail: 511 Farber Lakes Drive, Buffalo, NY 14221; Fax: (716) 631-9636 or 1-800-273-7397; Phone: (716) 631-2934 or 1-800-247-1466, Mon-Fri 8am-5pm
Non-formulary drug requests require a supporting statement that the requested drug is medically necessary because formulary alternatives would be less effective or have adverse effects for the patient
Applicable to non-formulary drug coverage determination requests
Prior authorization or other coverage rule exception requests require a supporting statement that the coverage rule is inappropriate given the patient's condition or would have adverse effects
For exceptions, timeframe begins when the supporting statement is obtained
Decision timeframes
- Expedited requests: decision notified no later than 24 hours from receipt
  Expedited determination if waiting may seriously jeopardize patient's life, health, or ability to regain maximum function
- Standard requests: decision notified no later than 72 hours from receipt

Documentation Required

Supporting statement required for non-formulary or exception requests

Provide a supporting statement showing medical necessity for non-formulary drug or exception requests. For non-formulary drug requests the statement must show the requested drug is medically necessary because formulary alternatives would be less effective or would have adverse effects for the patient. For prior authorization or other coverage-rule exception requests the statement must show the coverage rule is inappropriate given the patient’s condition or would have adverse effects.

Purixan 20 mg/mL oral suspension → mercaptopurine 2 mg/mL oral suspension
Ridaura 3 mg capsule → auranofin 3 mg capsule

Prior Authorization

Submit coverage determination / exception requests

Submit coverage determination or exception requests to Independent Health’s Pharmacy Department by mail, fax, or phone. Include the required supporting statement. Expedited requests will be decided and you notified no later than 24 hours from receipt; standard requests will be decided and you notified no later than 72 hours from receipt. For exception requests, the decision timeframe begins when the supporting statement is obtained.

Mail: Independent Health's Pharmacy Department, 511 Farber Lakes Drive, Buffalo, NY 14221
Fax: (716) 631-9636 or 1-800-273-7397
Phone: (716) 631-2934 or 1-800-247-1466 (Mon–Fri 8 a.m.–5 p.m.)

Product Removed	Suggested Generic Alternative	Rationale	Effective Date
Purixan 20 mg/mL oral suspension	mercaptopurine 2 mg/mL oral suspension	Generic Alternative on TS	2025-06-01
Ridaura 3 mg capsule	auranofin 3 mg capsule	Generic Alternative on TS	2025-06-01

FAQs / Background

Background: Independent Health removed branded products from the PDP 5 Tier formulary when an appropriate generic alternative is available. This change affects the listed branded oral suspension and capsule products and provides the suggested generic alternatives and the effective date for the deletions.

Q: How do I request a coverage determination or exception?

A: Submit your request to Independent Health's Pharmacy Department by mail (511 Farber Lakes Drive, Buffalo, NY 14221), fax ((716) 631-9636 or 1-800-273-7397), or phone ((716) 631-2934 or 1-800-247-1466, Mon–Fri 8 a.m.–5 p.m.). Include a supporting statement: for non-formulary drug requests, state the drug is medically necessary because formulary alternatives would be less effective or cause adverse effects; for coverage rule exceptions, state the rule is inappropriate or would cause adverse effects. Expedited requests will be decided within 24 hours of receipt; standard requests within 72 hours. For exceptions, timing begins when the supporting statement is obtained.