Medicare Advantage Part D Formulary (Drug List) — Coverage Criteria
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This document governs the Independent Health Medicare Advantage Part D drug formulary — which drugs are covered, applicable coverage restrictions (prior authorization, quantity limits, step therapy), and how members and prescribers can request exceptions or transition supplies.
No material clinical or coverage changes in this revision.
Coverage Criteria & Formulary Rules
General Formulary Coverage
Covered when ALL of the following general conditions are met:
See formulary and plan administrative guidance for specifics on PA, QL, ST, LA and other flags.
Transition and Emergency Supply
Temporary coverage during transitions:
After authorizing the temporary supply the plan will notify the member and prescriber and describe options to request an exception or identify alternatives.
Formulary coverage with utilization controls
Formulary entries are covered per plan benefits but may require adherence to listed utilization controls; coverage depends on tier and Requirements/Limits annotations.
Specific product-level PA/QL/ST conditions and exceptions (for example, PA not required for oncologists on select fentanyl products) are stated on the formulary lines and in prior authorization guidance.
Formulary coverage lines
Drugs listed are covered under the formulary with the tier and any attached requirements/limits.
Each product line in the formulary specifies its own tier and any requirement/limit flags that govern access and coverage.
Formulary access requirements
Coverage and access are tied to formulary tier and listed requirement/limit flags.
Providers must follow PA, meet QL, or satisfy ST/LA requirements listed for each formulary entry; failure to obtain required authorization may result in noncoverage.
If a drug is not listed on the formulary and an exception is not granted, the plan will not provide coverage for that drug. Members should contact Member Services to confirm coverage status. If the drug is not covered, members may request a list of similar covered alternatives from Member Services and discuss those options with their prescriber, or they may request a formulary exception following the plan’s exception process.
Formulary entries that are not explicitly listed — including specific formulations, strengths, or presentation types — may be excluded from coverage or subject to utilization controls such as Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Limited Access (LA). For drugs marked LA consult the Pharmacy Directory or Member Services for dispensing site restrictions. If a needed product is not on the formulary, providers or members can request a formulary exception per the plan’s exception procedures.
This section does not list any explicit exclusion conditions beyond the general rule that non‑formulary products are not covered unless an exception is approved. Definitions and the meaning of requirement flags and symbols used throughout the formulary are provided elsewhere (see page VI).
The document segment does not set out a standalone list of "not medically necessary" determinations. Medical necessity determinations are made in the context of the plan benefits and the formulary’s utilization controls (e.g., PA, QL, ST, LA) and via the exception process described in the formulary guidance.
This portion of the formulary does not enumerate specific items as "Not Medically Necessary." Coverage decisions rely on whether the drug is on the formulary, meets the plan’s benefit and utilization-control requirements, or is approved through the plan’s exception process.
Formulary Listings & Code Tables
| AMIKACIN_INJECTION_500MG_2ML | amikacin sulfate injection solution 500 mg/2ml |
| GENTAMICIN_IN_SALINE_IV | gentamicin in saline intravenous solution (multiple concentrations) |
| GENTAMICIN_SULFATE_EXTERNAL_CREAM_0.1% | gentamicin sulfate external cream 0.1% |
| GENTAMICIN_SULFATE_EXTERNAL_OINTMENT_0.1% | gentamicin sulfate external ointment 0.1% |
| GENTAMICIN_SULFATE_INJECTION_40MG_ML | gentamicin sulfate injection solution 40 mg/ml |
| NEOMYCIN_SULFATE_ORAL_TABLET_500MG | neomycin sulfate oral tablet 500 mg |
| STREPTOMYCIN_SULF_IM_INTRAMUSCULAR_1_GM | streptomycin sulfate intramuscular solution reconstituted 1 gm |
| TOBRAMYCIN_SULFATE_INJECTION | tobramycin sulfate injection solution |
| LINEZOLID_ORAL_SUSPENSION_100MG_5ML | linezolid oral suspension reconstituted 100 mg/5ml |
| LINEZOLID_ORAL_TABLET_600_MG | linezolid oral tablet 600 mg |
| XIFAXAN_200_Q_L | QL (9 EA per 3 days) for XIFAXAN 200 mg |
| XIFAXAN_550_PA | PA required for XIFAXAN 550 mg |
| ERLOTINIB_HCL_25_MG | erlotinib hcl oral tablet 25 mg — QL (90 EA per 30 days) |
| EVEROLIMUS_ORAL_TABLET_10_7.5_5_2.5_MG | everolimus oral tablet 10 mg, 7.5 mg, 5 mg, 2.5 mg — PA New Starts |
| EXKIVITY_ORAL_CAPSULE_40_MG | EXKIVITY ORAL CAPSULE 40 MG — PA New Starts; LA |
| OJJAARA_ORAL_TABLET_150_200_MG | OJJAARA ORAL TABLET 150 mg, 200 mg — PA New Starts; LA |
| PAZOPANIB_HCL_200_MG | pazopanib hcl oral tablet 200 mg — PA New Starts |
| PEMAZYRE_ORAL_TABLET_13.5_MG | PEMAZYRE ORAL TABLET 13.5 mg — PA New Starts; LA |
| MOUNJARO_PEN_INJECTORS | MOUNJARO SUBCUTANEOUS SOLUTION AUTO-INJECTOR (multiple strengths) — PA; QL; EDS |
| OZEMPIC_PEN_INJECTORS | OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR (multiple strengths) — PA; QL; EDS |
| LANTUS_SOLOSTAR_100_UNIT_ML | LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML — EDS |
| INSULIN_GLARGINE_MAX_SOLOSTAR_300_UNIT_ML | insulin glargine max solostar subcutaneous solution pen-injector 300 unit/ml — EDS |
| INSULIN_LISPRO_PEN | insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml — EDS |
| OMNIPOD_DEVICES | OMNIPOD devices and pods (various gens) — QL; EDS |
| INSULIN_SYRINGES_30G_31G | insulin syringe 30-gauge and 31-gauge |
| MOUNJARO_PEN | MOUNJARO SUBCUTANEOUS SOLUTION AUTO-INJECTOR (multiple strengths) |
| OZEMPIC_PEN | OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR (multiple strengths) |
| OMNIPOD_5_G7_KITS_PODS | OMNIPOD 5 G7 kits and pods — QL |
| OMNIPOD_DASH_GEN4_PODS | OMNIPOD DASH pods (Gen 4) — QL |
| DABIGATRAN_ETEXILATE_110_150_75_MG | dabigatran etexilate mesylate oral capsule 110 mg, 150 mg, 75 mg |
| ELIQUIS_STARTER_PACK_5_MG | ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 5 MG |
| ENOXAPARIN_INJECTION_PREFILLED | enoxaparin sodium injection solution prefilled syringe (multiple strengths) |
| LEUKINE_INJECTION_250_MCG | LEUKINE INJECTION SOLUTION RECONSTITUTED 250 MCG |
| NEUPOGEN_INJECTION_300_MCG_ML | NEUPOGEN INJECTION SOLUTION 300 MCG/ML; prefilled syringe options |
| CANDESARTAN_CILEXETIL_TABLETS | candesartan cilexetil oral tablet (multiple strengths) — EDS |
| FILSPARI_200_400_MG | FILSPARI ORAL TABLET 200 MG, 400 MG — PA; LA; QL (30 EA per 30 days) |
| CORLANOR_ORAL_SOLUTION_5MG_5ML | CORLANOR ORAL SOLUTION 5 mg/5ml — PA; Prior auth not required for cardiologists; EDS |
| PRALUENT_AUTO_INJECTOR | PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML — PA New Starts; EDS |
| REPATHA_PRODUCTS | REPATHA PUSHTRONEX and prefilled syringe systems — PA New Starts; EDS |
| DUPIXENT_PREFILLED_200_300MG | DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML — PA |
| CLINISOL_SF_INTRAVENOUS_15% | CLINISOL SF INTRAVENOUS SOLUTION 15% — BD |
| CLINIMIX_VARIANTS | Multiple CLINIMIX and CLINIMIX/DEXTROSE formulations — BD |
| BYLVAY_PELLETS | BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE 200 MCG, 600 MCG — PA; LA |
| XIFAXAN_200_MG | XIFAXAN ORAL TABLET 200 MG — QL (9 EA per 3 days) |
| XIFAXAN_550_MG | XIFAXAN ORAL TABLET 550 MG — PA |
| VOWST_ORAL_CAPSULE | VOWST ORAL CAPSULE — PA; LA; QL (12 EA per 3 days) |
Prior Authorization, Step Therapy & Documentation
Prior Authorization Required — Certain drugs require PA
Independent Health requires prior authorization (PA) for many drugs listed in the formulary. Drugs annotated with "PA" in the Requirements/Limits column require approval before dispensing; failure to obtain required PA may result in denial or noncoverage.
- PA flags appear throughout the formulary for specialty, oncology, high‑tier, injectable and select oral agents.
- PA may be specialty‑ or prescriber‑specific (for example, PA not required for oncologists, nephrologists, endocrinologists, cardiologists, dermatologists in select entries).
- Drugs marked "PA New Starts" require PA for new therapy starts; ongoing therapy may have different handling.
PA required for listed specialty/oncology agents
Many specialty and oral oncology agents are listed with PA or "PA New Starts." Providers must submit PA documentation for medical necessity, therapy pack/quantity limits (QL), andany limited‑access (LA) or extended‑day supply (EDS) indicators noted in the Requirements/Limits column.
- Examples: numerous oral oncology agents and high‑tier specialty products are marked PA New Starts; many also have LA and QL flags.
- When a drug lists LA, it may be available only at certain pharmacies — consult the Pharmacy Directory or Member Services.
- EDS entries indicate extended day supply rules (e.g., 90‑ or 100‑day fills) which must be documented with the PA request when applicable.
Prior authorization flags — numerous drugs require PA/PA New Starts
Prior authorization applies to many product types: injectables/specialty biologics, select antidiabetic and GLP‑1 injectables, anticonvulsants, dementia agents, immunologics, select topicals, and other high‑tier products. Check product‑specific Requirements/Limits for PA, QL, LA, ST, BD, or EDS indicators.
- Examples: MOUNJARO, OZEMPIC, TRULICITY, several GLP‑1 and antidiabetic injectables are marked PA and QL; some injectables (Neupogen, Leukine, Retacrit, Udenyca, etc.) require PA.
- Topical agents and dermatology entries may have PA with specialty exceptions (e.g., dermatologists or oncologists).
- Anticonvulsants and select dementia/cholinesterase inhibitors may show PA New Starts, QL, EDS, or LA flags.
Prescriber Statement for Exceptions & Documentation Expectations
Prescribers must include supporting clinical documentation when requesting PA or an exception. For formulary or tiering exceptions, prescriber statements are required and Independent Health generally issues decisions within 72 hours of receiving supporting documentation (24 hours for expedited requests when clinically warranted).
- Prescriber supporting statement must explain medical necessity for exception or waiver of PA/QL/ST.
- Expedited (fast) decisions are available when waiting could seriously harm the enrollee; expedited decisions generally completed within 24 hours of prescriber documentation.
- Contact Member Services or consult the Pharmacy Directory for submission instructions and specialty/pharmacy exceptions.
Prior Authorization Denial Risk & Denial Triggers from Requirements/Limits
Requests that do not meet the listed Requirements/Limits (PA, LA, QL, ST, BD, EDS) or lack required documentation may be denied. Noncompliance with PA or QL controls is a common denial trigger — obtain approvals and provide required clinical documentation to reduce denial risk.
- Denials may occur when PA is not obtained prior to dispensing or when documentation does not support medical necessity.
- PA or QL noncompliance may lead to noncoverage. Verify Requirements/Limits on the formulary before dispensing.
- For drugs with BD or Part B/Part D uncertainty, submit use/setting details to determine coverage responsibility.
Quantity Limit Enforcement & Documentation
Quantity limits (QL) and therapy‑pack limits listed in the Requirements/Limits column must be honored. When submitting PA requests include quantity and pack‑specific justification; QL noncompliance without PA/documentation may result in denial.
- Examples: QL entries (e.g., 2 ML per 28 days, 3 ML per 28 days, 120 EA per 30 days) are shown for GLP‑1s, migraine injectables, oncology therapy packs, and others.
- Therapy pack / titration pack limits are indicated (therapy pack counts per 28/30/365 days) and require appropriate documentation for overrides.
- Include exact requested quantity and rationale with PA submission to prevent processing delays.
Step Therapy Requirement — sequences and exceptions
Step therapy (ST) is used for select agents; drugs marked "ST" require trial and failure of specified preferred agents before coverage of non‑preferred alternatives. This formulary excerpt does not include step sequences — consult the full policy or contact Member Services for the required step sequences and alternatives.
- ST appears for select products (example: febuxostat shows ST).
- No explicit step therapy sequences are shown in this segment — providers must refer to the full policy or pharmacy documents for required first‑line agents and allowable exceptions.
- Step therapy and tiering may vary by product; prescribers can request exceptions with supporting clinical rationale.
Step Therapy Requirements
| Policy item | Requirement / Effect |
|---|---|
| Drugs labeled 'ST' in the Requirements/Limits column | |
| Subject to step therapy — member must try and fail preferred agents listed by the plan before the ST drug is covered |
| Drug group / flag | Required action |
|---|---|
| Drugs marked 'ST' | |
| Prior trial(s) of preferred agent(s) per formulary step therapy must be documented before coverage of the alternative agent |
| Product examples | Utilization control |
|---|---|
| VALTOCO (nasal liquid) — various strengths | |
| Requirements/Limits = PA New Starts; prior authorization not required if prescribed by neurologists (specialty exception) |
| Drug | Formulary flag / implication |
|---|---|
| Febuxostat (oral tablet 40 mg, 80 mg) | |
| Requirements/Limits = ST; step therapy requirement applies before coverage |
| Access control | Meaning |
|---|---|
| PA New Starts | |
| Prior authorization required for new therapy starts; coverage may be denied if PA not obtained |
| Product | Requirements/Limits |
|---|---|
| OPIPZA oral film (2 mg, 5 mg, 10 mg) | |
| Requirements/Limits = ST (step therapy); some strengths also list QL |
| Control type | Example / effect |
|---|---|
| PA New Starts for higher-tier products | |
| Certain Tier 5 oral oncology and specialty agents are designated PA New Starts — new therapy initiations require prior authorization |
| Drug | Requirement |
|---|---|
| LYBALVI (oral tablet) — various strengths | |
| Requirements/Limits = PA New Starts; prior authorization required for new starts |
| Agent(s) | Requirements/Limits |
|---|---|
| Eltrombopag formulations (e.g., 12.5 mg, 25 mg; 50 mg, 75 mg) | |
| Requirements/Limits = PA; prior authorization required prior to coverage (some strengths also list QL) |
| Drug | Formulary flag / implication |
|---|---|
| Aliskiren fumarate (oral tablet 150 mg, 300 mg) | |
| Requirements/Limits = ST; step therapy applies before coverage |
| Product | Requirement |
|---|---|
| QELBREE oral capsule (100 mg, 150 mg, 200 mg) | |
| Requirements/Limits = ST; QL (30–60 EA per 30 days); step therapy required before coverage |
| Agent / example | Requirements/Limits |
|---|---|
| EUCRISA and similar topical agents (examples in dermatology section) | |
| Some entries are labeled 'ST' indicating step therapy applies before coverage |
| Product | Formulary flag / effect |
|---|---|
| TALICIA oral capsule delayed release (250-12.5-10 mg) | |
| Requirements/Limits = ST; step therapy requirement applies |
Quantity Limits by Product
Site-of-Care & Dispensing Restrictions
Definitions & Abbreviations
Background & Scope
The formulary is organized by medical condition and groups both brand and generic products under therapeutic sections. Biological products and biosimilars are discussed; the plan may add biosimilar versions and apply substitution or tiering per plan rules and applicable state law regarding interchangeability.
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