CurrentIndependent HealthPolicy N/A

Formulary changes for select pharmacy products

Summarizes formulary deletions and alternatives for specific pharmacy products and explains how providers may request coverage determinations or exceptions; affects Independent Health members and prescribing providers.

Policy Summary

PayerIndependent Health

PolicyFormulary changes for select pharmacy products

Policy CodePolicy N/A

Change TypeFormulary deletions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionInclude a supporting statement when requesting coverage for a non‑formulary drug or an exception showing the requested drug is medically necessary or the rule is inappropriate.

SourceLink

POLICY UPDATE CHANGES

CIPRO HC SUS 0.2-1% OT removed from formulary (Formulary Deletion).

FYCOMPA SUS 0.5MG/ML removed from formulary (Formulary Deletion).

2formulary deletions listed

2026-04-01effective date

Coverage Criteria

Effective 4/1/2026, the following products will be removed from the Independent Health formulary: CIPRO HC SUS 0.2-1% OT and FYCOMPA SUS 0.5MG/ML. CIPRO HC SUS 0.2-1% OT is a formulary deletion in the Otic Agents class with the listed alternative CIPROFLOX/HC SUS 0.2-1% OT (reason: Generic Alternative on T4). FYCOMPA SUS 0.5MG/ML is a formulary deletion in the Anticonvulsants class with the listed alternative PERAMPANEL SUS 0.5MG/ML (reason: Generic Alternative on T5).

Provider Actions and Requirements

Prior Authorization

Prior Authorization / Exception Requirement

Prior authorization or a coverage-rule exception is required for certain non-formulary drugs and for requests that deviate from standard coverage rules. To request coverage determination or an exception, contact Independent Health's Pharmacy Department by mail, fax, or phone (see items). Expedited requests: decision notified within 24 hours of receipt. Standard requests: decision within 72 hours of receipt. For exceptions, the time frame begins when we obtain your supporting statement. We will expedite if the patient's life, health, or ability to regain maximum function may be seriously jeopardized by waiting.

Mail: Independent Health Pharmacy Department, 511 Farber Lakes Drive, Buffalo, NY 14221
Fax: (716) 631-9636 or 1-800-273-7397

Policy Summary

PayerIndependent Health

PolicyFormulary changes for select pharmacy products

Policy CodePolicy N/A

Change TypeFormulary deletions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionInclude a supporting statement when requesting coverage for a non‑formulary drug or an exception showing the requested drug is medically necessary or the rule is inappropriate.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation Required

Supporting Statement Required for Non‑Formulary and Exception Requests

Requests for a non-formulary drug or an exception to a coverage rule must include a supporting statement from the prescriber. The statement must explain why the requested drug is medically necessary and why formulary alternatives are inappropriate or would cause adverse effects for the patient. For prior authorization or other coverage-rule exception requests, the statement must document why the coverage rule would be inappropriate for the patient's condition or would have adverse effects.

Supporting statement required for non-formulary drug requests demonstrating medical necessity and why formulary alternatives are less effective or would cause harm
Supporting statement required for prior authorization or coverage-rule exceptions documenting why the rule is inappropriate or harmful for this patient
Requests missing a supporting statement demonstrating medical necessity may be denied

Step Therapy

Formulary Alternative Expectation

Prescribers are expected to consider and document formulary alternatives before requesting non-formulary coverage. When a therapeutically appropriate formulary alternative exists (including generics noted on the formulary), the alternative should be used unless the supporting statement documents that the alternative would be less effective or would cause adverse effects for the patient.

If a generic or other formulary alternative is available, that alternative is expected to be used (e.g., ciprofloxacin/other formulary otic alternatives; perampanel vs brand where generic available)
When requesting a non-formulary product, explicitly state why each formulary alternative is inappropriate or would cause harm