Medicare Advantage Part D Formulary (Drug List) — Independent Health Employer Group 2026
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This document is Independent Health's Medicare Advantage Employer Group Part D formulary describing covered drugs, restrictions (prior authorization, quantity limits, step therapy), member rights to exceptions, and how to find drugs in the formulary. It affects plan members, prescribers, and network pharmacies using the Independent Health Medicare Advantage Employer Group Part D benefit.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules & Controls
Formulary coverage rules and member protections
Covered when ALL of the following are met:
See Evidence of Coverage for details (source: Independent Health formulary description).
Requirements/Limits flags appear in the formulary table and must be followed; failure to obtain PA may result in non-coverage.
Members may request exceptions; plan provides notice and transition supplies per CMS rules.
Exceptions may waive non-formulary status, PA, QL, or ST where medically justified.
PA / New Starts
Coverage and utilization management flags present for listed drugs:
Examples in the formulary include WEGOVY, REPATHA formulations, and multiple oncology agents.
Check the formulary row for any specialist exemptions or notes.
Providers should follow the payer's PA process and submit required documentation.
Quantity limits
Quantity limited products (examples shown):
Requests exceeding listed QL may require prior authorization or be denied.
Operate per the Requirements/Limits column for each product.
Providers should submit quantity justification per plan guidance.
Formulary coverage rows / Utilization controls
Coverage and utilization controls are listed per product as Tier = X and Requirements/Limits = Y:
Each line in the formulary indicates the operational controls that must be met for coverage.
Formulary coverage with utilization controls
Formulary coverage is indicated by listing drug, strength, Tier and any Requirements/Limits; coverage requires meeting the noted Requirements/Limits for each product.
See the specific formulary line for product-level controls; absence from the list may indicate non-coverage unless an exception is granted.
Formulary placement and utilization controls
Formulary placement and utilization controls — how to read the table:
Specific medical necessity criteria and payer PA forms are not included in this excerpt; consult the plan's PA process and the formulary legend (page VII) for operational definitions.
If a drug is not listed on the formulary and an exception is not granted, Independent Health will not cover the drug. Members should contact Member Services to confirm coverage and may either request a list of covered therapeutic alternatives to discuss with their prescriber or submit a formal exception request for Independent Health to consider.
Drugs labeled with ENH in the Requirements/Limits column are not normally covered under the Medicare Prescription Drug Plan. Amounts paid for ENH drugs do not count toward total drug costs and are not eligible for Extra Help.
The content shown in these chunks is a table-of-contents style listing of formulary line items and requirement flags. It does not contain full medical necessity criteria, prior authorization forms, or detailed exclusion language; those detailed criteria are provided elsewhere in the plan materials.
WEGOVY entries in the formulary are listed with a Requirements/Limits note that includes "Not covered for weight management" for the strengths shown, along with prior authorization and quantity limit annotations.
The formulary lines for isotretinoin products indicate differing formulary statuses: the document notes "Accutane generic covered, Absorica generic is non-formulary" (and shows Absorica and related isotretinoin entries). This reflects that one generic/formulation may be covered while another brand or generic formulation is non‑formulary.
No explicit exclusion lists are present in these excerpts. The absence of a product from the displayed lines, or lack of an explicit exclusion statement here, does not imply automatic coverage; full coverage/exclusion determinations require consulting the complete formulary and supporting plan documents.
Within the provided chunks there are no explicit "not medically necessary" statements for individual products. The excerpt lists tiers and program flags (PA, QL, EDS, LA, ENH) but does not include product-specific 'not medically necessary' determinations.
What Prescribers and Pharmacies Must Do
Prior authorization required for PA‑flagged drugs
Certain drugs listed on the formulary require prior authorization (PA) before the plan will cover them. The Requirements/Limits column of the formulary identifies PA-designated products and the 'Are there any restrictions on my coverage?' section explains that failure to obtain PA may result in noncoverage.
- Check the Requirements/Limits column for 'PA' before prescribing or dispensing.
- Obtain prior authorization per Independent Health procedures to avoid claim denial or member financial liability.
PA applies to listed products (examples: ARIKAYCE, topical/patch items)
Drugs with 'PA' in the Requirements/Limits column require prior authorization for coverage; examples in the formulary include ARIKAYCE (marked 'PA; LA') and several topical and patch products listed with PA.
- Verify PA designation on each product line (e.g., ARIKAYCE PA; LA).
- Follow the plan's PA submission process for these listed products.
Prior authorization indicated by 'PA' or 'PA New Starts'
Some formulary entries are labeled 'PA' or 'PA New Starts,' indicating prior authorization is required either for coverage generally or specifically for new therapy starts; prescribers must submit PA requests per the plan's process.
- For products marked 'PA New Starts', obtain PA prior to initiating therapy.
- For products marked 'PA' (without 'New Starts'), obtain PA as specified on the product line.
PA New Starts required for select products (examples: ZTALMY, nasal agents)
Certain products in the formulary are designated 'PA New Starts' (e.g., ZTALMY oral suspension, some nasal seizure rescue products) which requires prescribers to obtain prior authorization when initiating therapy; some entries note specialty exceptions for neurologists.
- Obtain PA for new starts of 'PA New Starts' products before dispensing.
- If prescriber is a neurologist, confirm whether the formulary exempts that specialty for specific nasal products (e.g., NAYZILAM/VALTOCO notes).
Prior authorization required for various listed drugs
Multiple specific products are marked 'PA' in the Requirements/Limits column and therefore require prior authorization for coverage (examples include several promethazine formulations and other listed items).
- Review each formulary line for PA flags and any conditional notes (e.g., age exceptions).
- Submit PA documentation as required to support medical necessity.
PA New Starts required for many oral oncology agents
Many oral oncology agents are labeled 'PA New Starts' in the formulary, indicating prior authorization is required when initiating these therapies and that claims for new starts may be denied without PA.
- Obtain prior authorization before initiating oral oncology agents flagged 'PA New Starts'.
- Expect PA to be required for numerous high‑cost oral oncology products listed on Tier 5.
Prior authorization required for specified products (examples: MAVYRET, PREVYMIS)
Selected high‑tier products listed with 'PA' (e.g., MAVYRET, PREVYMIS) require prior authorization before coverage will be approved; prescribers should submit PA per plan instructions.
- Confirm PA status on the product line (e.g., PREVYMIS marked 'PA').
- Provide necessary clinical information to support the PA request.
Prior authorization and combined control flags apply
Products labeled 'PA New Starts' or otherwise marked 'PA' or 'PA; QL' require prior authorization; some entries also pair PA with other controls such as quantity limits or limited access (LA).
- If a product shows combined flags (e.g., 'PA; QL'), meet both PA and QL conditions to avoid denial.
- Check for LA (limited access) or other site restrictions on the same line.
PA required for multiple specialty/high‑cost agents
Multiple listed drugs show 'Requirements/Limits = PA' on their formulary line (examples include eltrombopag, RETACRIT, UDENYCA, VOYDEYA), and prior authorization must be obtained for these products before coverage.
- Obtain PA for hematology and other specialty agents flagged 'PA'.
- Include diagnosis and prior therapy documentation with the PA when required.
Prior authorization required for select high‑tier products (examples listed)
Certain high‑tier and specialty products (WEGOVY, KERENDIA, REPATHA formulations, JUXTAPID and others) carry PA or 'PA New Starts' flags; prescribers must secure PA per the formulary to obtain coverage.
- Check the product line for PA or 'PA New Starts' prior to prescribing.
- For REPATHA and similar injectables, PA is commonly required for new starts.
PA required for specified specialty drugs (DUPIXENT, OTEZLA, PANRETIN, etc.)
Several specialty medications (e.g., DUPIXENT, OTEZLA, PANRETIN, methoxsalen, deferasirox formulations) are listed with 'PA' or 'PA New Starts' in the Requirements/Limits column and require prior authorization before coverage.
- Submit PA requests for these agents with clinical justification and any required forms.
- Check for associated LA or QL flags on the same formulary lines.
Prior authorization required for multiple listed products (see formulary lines)
Prior authorization (PA) is required for multiple listed products (examples: deferasirox soluble tablets, LINZESS strengths, XIFAXAN 550 mg, BYLVAY, GATTEX, EVRYSDI) — follow the PA process for each PA‑flagged line and note any QL or LA designations.
- Review the Requirements/Limits field on each product line for PA, QL, LA, or EDS.
- Provide supporting documentation (diagnosis, prior therapies) as part of the PA submission.
PA required for listed PA items (RIVFLOZA, CORTROPHIN GEL, testosterone products)
Several high‑tier or specialty products (e.g., RIVFLOZA, CORTROPHIN GEL, INCRELEX, various testosterone formulations) are marked 'PA' and require prior authorization for coverage; some also list EDS or LA.
- Obtain PA for CORTROPHIN, RIVFLOZA and listed specialty hormonal products before dispensing.
- When EDS is present alongside PA, include evidence and any edit‑related documentation requested by the plan.
Step therapy applies to ST‑designated drugs
Some drugs are subject to step therapy (marked 'ST' in the Requirements/Limits column); prescribers must follow the plan's step therapy rules and document attempts and failures on preferred agents before coverage of step‑required alternatives is approved.
- Check for 'ST' on the formulary line and follow the step sequencing described in the plan materials.
- Include documentation of prior treatment trials and outcomes when requesting PA or exceptions for ST‑designated drugs.
Follow step therapy (ST) rules for ST‑flagged products
Drugs listed with 'ST' in Requirements/Limits are subject to step therapy; the formulary and the 'Are there any restrictions on my coverage?' section describe that the member may need to try preferred drugs first before alternatives are covered.
- Verify ST designation and ensure prior trial of preferred agent(s) is documented.
- If requesting an exception to step therapy, prescriber must provide medical rationale per the exception process.
Step edits and other utilization management implied by EDS / PA New Starts / LA
Some formulary entries include 'EDS', 'PA New Starts; LA' or other edit flags that imply utilization management like step edits, limited access, or evidence/documentation requirements; prescribers should submit required evidence to avoid edit‑related denials.
- When a product shows 'EDS', expect plan edits and include supporting documentation to satisfy evidence requirements.
- Products with 'PA New Starts; LA' may have limited availability and require PA plus site‑of‑care justification.
Combined prior authorization and quantity‑limit controls (PA New Starts; QL)
Some products combine prior authorization and quantity limits (e.g., entries showing 'PA New Starts; QL' such as EXXUA), requiring prescribers to secure PA and to adhere to QL thresholds when prescribing.
- For products marked with both PA and QL, submit PA that documents the clinical need for requested quantity.
- Anticipate claim edits if QL is exceeded without PA.
Step therapy or PA New Starts apply to certain agents
Some agents carry 'ST' or 'PA New Starts' flags (for example febuxostat is marked 'ST' and many oncology/antiandrogen agents are 'PA New Starts'), indicating that either a prior step is required or PA is required for new therapy starts.
- Confirm whether ST or PA New Starts applies on the product line before prescribing.
- Document prior therapies (for ST) or obtain PA for new starts as required.
Prior authorization required — check formulary flags and legend
Prior authorization is required for many listed products; the formulary flags (PA, PA New Starts) and the 'Are there any restrictions on my coverage?' section instruct prescribers to obtain authorization to prevent denial of coverage.
- Always check the Requirements/Limits field and obtain required PA prior to dispensing.
- If unsure, contact Independent Health Member Services or consult the formulary index and legend (page VII) for definitions.
Denial risk if prior authorization not obtained
Failure to obtain required prior authorization for PA‑flagged drugs may result in the plan not covering the drug or the member being liable for cost; obtain PA and submit necessary clinical documentation to avoid denial.
- Obtain PA before dispensing PA‑flagged items for new starts and ongoing therapy when required.
- Advise members that coverage may be denied without PA and that they can request an exception if clinically indicated.
Provide setting/use info for Part B vs Part D determinations (BD flag)
If a drug's coverage is determined to fall under Medicare Part B rather than Part D (BD flag), submission of information about the drug's use and setting may be required; if Part B coverage is found, the drug will not be covered under the Part D tier listing.
- Provide setting/use details when requested to allow the plan to determine Part B vs Part D coverage.
- Do not assume Part D tier cost‑sharing applies if BD is indicated; verify with Member Services or Evidence of Coverage.
PA/QL/EDS/LA flags may trigger restrictions or denials
Products flagged 'PA', 'QL', 'EDS', or 'LA' may trigger coverage restrictions, edits, or denials if the specified program requirements are not met; prescribers should follow the formulary's Requirements/Limits for each listed product.
- When a product shows QL, ensure the quantity requested does not exceed the listed limit or include PA to justify overage.
- When EDS appears, include required evidence or anticipate edit‑based review.
PA required for new therapy starts ('PA New Starts')
Products labeled 'PA New Starts' (e.g., many oncology oral agents, ZTALMY, some nasal rescue products) require prior authorization when initiating therapy; claims for new starts may be denied without PA.
- Secure PA before starting treatment with 'PA New Starts' drugs.
- Document that the prescription represents a new start when submitting PA.
Documentation and quantity edits can trigger claim denials
Products with EDS (evidence/edit standard) or QL (quantity limit) may be subject to claim edits or automatic rejection if documentation is missing or the requested quantity exceeds the listed limit; include quantity justification and supporting clinical documentation with PA or exception requests.
- Provide quantity and clinical rationale when requesting amounts above QL.
- For EDS entries, include evidence of medical necessity per plan requirements.
Follow formulary requirement flags (PA, QL, EDS, ST, LA) to avoid denials
Formulary requirement flags (PA, QL, EDS, BD, ST, LA) across the drug list indicate specific utilization controls and denial risks; prescribers must follow the flagged requirements to avoid coverage denial.
- Consult the legend (page VII) for precise meanings of each flag before submitting PA or exception requests.
- Address every flagged requirement on the product line when completing authorizations.
Quantity limits overage and denial triggers
Exceeding stated quantity limits (e.g., Paxlovid pack QLs or sacubitril‑valsartan QL entries) or failing to meet PA/LA/EDS/ST requirements may result in denial or override; check the QL shown on each product line and obtain PA when requesting amounts above the limit.
- Compare the requested supply to the product's QL (e.g., Paxlovid pack QLs per 365 days).
- If over QL, submit PA with clinical justification or request an exception.
PA required for PA‑coded drugs (examples: eltrombopag, RETACRIT, UDENYCA)
Products flagged 'PA' or 'PA; QL' (for example eltrombopag, RETACRIT, UDENYCA, VOYDEYA) require prior authorization; claims submitted without the required PA may be denied.
- Obtain PA for products with PA or PA; QL flags prior to dispensing.
- Include QL‑related justification when PA covers quantities above the listed limit.
PA required entries (examples: WEGOVY, KERENDIA)
Coverage may be denied for listed products (e.g., WEGOVY, KERENDIA) where the line indicates 'PA' or 'PA New Starts'; verify PA status and obtain authorization to prevent claim denial.
- Check the product line for PA or PA New Starts before prescribing.
- Submit clinical documentation as required by the plan's PA process.
Quantity limit overage may trigger denial
Exceeding quantity limits specified on formulary lines (e.g., sacubitril‑valsartan 60 EA/30 days, VASCEPA/icosapent ethyl QLs) may cause claim rejection or require PA; adhere to QL values or seek authorization for overages.
- Confirm QL values on each product line before prescribing.
- Request PA and provide justification if a higher quantity is clinically necessary.
PA required for certain specialty agents (e.g., DUPIXENT)
Some specialty/high‑tier agents (e.g., DUPIXENT auto‑injector and prefilled syringe) are PA‑flagged; prior authorization must be obtained for these specialty agents to receive coverage.
- Submit PA for specialty biologics, including brand and formulation details (auto‑injector vs prefilled syringe).
- Include clinical indication and prior therapy documentation as required.
EDS and QL edit requirements may trigger denials (examples provided)
Entries marked 'EDS' or 'QL' denote plan edits or quantity limits that require fulfillment of edit criteria or documentation; failure to meet these could result in denial (examples: dimethyl fumarate QL 60 EA per 30 days; teriflunomide 7 mg QL 30 EA per 30 days).
- Provide required evidence and adhere to specified QL to avoid claim edits.
- If edits block the claim, submit PA or exception with supporting clinical information.
Failure to meet Requirements/Limits can lead to denial
Coverage may be denied if prior authorization (PA) or other program‑specific requirements (LA, BD, EDS) listed for a product are not met; prescribers should follow the Requirements/Limits field on each formulary line.
- Before prescribing, review the product's Requirements/Limits and obtain PA or other documentation as indicated.
- Advise members about potential coverage denial if requirements are unmet and about exception processes.
High‑tier (Tier 4–5) drugs require adherence to PA/QL/EDS/LA conditions
High‑tier drugs (Tiers 4–5) often include Requirements/Limits such as PA, LA, QL, or EDS; claims for these high‑cost items risk denial if those conditions are not satisfied.
- Anticipate PA and additional documentation for Tier 4–5 medications.
- Use the exception/tiering request process when clinically justified to seek coverage or lower cost‑sharing.
Denial risk when PA/QL/EDS requirements are not met
Claims for products listed with PA, QL, or EDS may be denied if those requirements are unmet; prescribers should include required documentation (diagnosis, prior therapies, quantity justification) in PA or exception submissions.
- Follow PA/EDS procedures and provide medical necessity documentation to support requests.
- Use the formulary legend (page VII) and the plan's PA forms to ensure submissions meet requirements.
Drug Entries and Coding Notes
| ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML | Tier = 5; Requirements/Limits = PA; LA |
| VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG | Tier = 5 |
| KLOXXADO NASAL LIQUID 8 MG/0.1ML | Tier = 3 |
| OPVEE NASAL SOLUTION 2.7 MG/0.1ML | Tier = 3 |
| linezolid oral suspension reconstituted 100 mg/5ml | Tier = 5 |
| daptomycin intravenous solution reconstituted 500 mg | Tier = 5 |
| NDCs not provided | Product names, strengths, tiers and Requirements/Limits are listed in the formulary table; NDCs are not included in these chunks. |
| buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 5 mcg/hr, 7.5 mcg/hr | Tier = 4; QL (4 EA per 28 days) |
| fentanyl transdermal patch 72 hour 100 mcg/hr, 75 mcg/hr | Tier = 4; QL (30 EA per 30 days) |
| fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr | Tier = 4; QL (15 EA per 30 days) |
| hydrocodone bitartrate er oral tablet abuse-deterrent | Tier = 4; QL (30 EA per 30 days) |
| methadone hcl oral tablet 5 mg and 10 mg | Tier = 2; methadone hcl oral tablet 5 mg Requirements/Limits = QL (240 EA per 30 days); 10 mg listed Tier = 2 |
| tramadol hcl er oral tablet 100 mg, 200 mg | Tier = 4; QL (30 EA per 30 days) |
| NDCs not provided | Formulary presents product lines and QL examples; billing codes/NDCs are not listed in these chunks. |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| NDCs not provided | The document lists product names, strengths, packaging, tiers and Requirements/Limits but does not include NDC or CPT/ICD codes in these chunks. |
| potassium chloride intravenous solution (various concentrations) | Tier = 2; Requirements/Limits may vary |
| potassium chloride oral packet 20 meq | Tier = 2; Requirements/Limits = EDS |
| potassium chloride oral solution 20 meq/15ml | Tier = 2; Requirements/Limits = EDS |
| deferasirox oral tablet 180 mg, 360 mg, 90 mg | Tier = 3; Requirements/Limits = EDS |
| deferasirox oral tablet soluble 125 mg | Tier = 4; Requirements/Limits = PA; EDS |
| deferasirox oral tablet soluble 250 mg, 500 mg | Tier = 5; Requirements/Limits = PA |
| tolvaptan (hyponatremia) oral tablet 15 mg | Tier = 5; Requirements/Limits = PA; QL (30 EA per 30 days) |
| tolvaptan oral tablet 30 mg | Tier = 5; Requirements/Limits = PA |
| tolvaptan oral tablet therapy pack (various) | Tier = 5; Requirements/Limits = PA; QL (60 EA per 30 days) |
| LINZESS ORAL CAPSULE 145 MCG, 72 MCG | Tier = 3; Requirements/Limits = QL (30 EA per 30 days); EDS |
| LINZESS ORAL CAPSULE 290 MCG | Tier = 3; Requirements/Limits = EDS |
| XIFAXAN ORAL TABLET 200 MG | Tier = 4; Requirements/Limits = QL (9 EA per 3 days) |
| XIFAXAN ORAL TABLET 550 MG | Tier = 5; Requirements/Limits = PA |
| sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg | Tier = 2; Requirements/Limits = ENH; QL (10 EA per 30 days) |
| tadalafil oral tablet 10 mg, 20 mg (ed) | Tier = 2; Requirements/Limits = ENH; QL (6 EA per 30 days) |
| RIVFLOZA SUBCUTANEOUS SOLUTION 80 MG/0.5ML | listed product and strength |
| RIVFLOZA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 128 MG/0.8ML, 160 MG/ML | listed product and strengths |
| CORTROPHIN GEL SUBCUTANEOUS PREFILLED SYRINGE 40 UNIT/0.5ML, 80 UNIT/ML | listed product and strengths |
| INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML | listed product and strength |
| LILETTA (52 MG) INTRAUTERINE DEVICE 20.1 MCG/DAY | listed IUD product and release rate |
| NDCs not provided | These product entries list formulations, tiers and PA/QL/LA flags but do not include billing codes in the cited chunks. |
| testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) | various formulations and strengths listed; Requirements/Limits = PA; EDS for many entries |
| testosterone transdermal gel 20.25 mg/act (1.62%) | Tier = 2; Requirements/Limits = PA; EDS |
| testosterone transdermal solution 30 mg/act | Tier = 4; Requirements/Limits = PA; EDS |
Step Therapy & 'PA New Starts' Controls
| Drug / Product | Requirement (ST flag) |
|---|---|
| General — formulary step therapy policy (ST indicates step therapy applies) | |
| See formulary 'Requirements/Limits' column for specific products marked 'ST' |
| What ST means | Provider action / Reference |
|---|---|
| 'ST' in Requirements/Limits indicates the product is subject to step therapy (try specified preferred drug(s) first) | |
| Follow the formulary's step therapy rules described under 'Are there any restrictions on my coverage?' and the Requirements/Limits column |
| Anticonvulsant product(s) | Requirement / Flag shown |
|---|---|
| DIACOMIT (stiripentol) — oral capsule/packet entries | PA New Starts; LA |
| EPIDIOLEX (cannabidiol) — oral solution | PA New Starts; LA |
| LEVETIRACETAM / LAMOTRIGINE / other anticonvulsants (selected strengths) — various entries | EDS or PA New Starts indicated on some lines |
| Product | Requirement / Note |
|---|---|
| EXXUA (and EXXUA titration pack) | Requirements/Limits = PA New Starts; QL shown — implies prior authorization required for new starts; explicit step sequence not provided in excerpt |
| Product | Requirement |
|---|---|
| febuxostat (listed among antigout agents) | Requirements/Limits = ST (step therapy applies) |
| Oncology / antiandrogen examples | Requirement / Flag |
|---|---|
| Abiraterone acetate, bicalutamide, abiraterone-class agents (antiandrogens) | Requirements/Limits = PA New Starts |
| Lenalidomide, pomalidomide, other antineoplastics | Requirements/Limits = PA New Starts (many oncology oral agents flagged) |
| Various oral oncology agents (multiple listings) | Requirements/Limits = PA New Starts; some also LA or QL |
| Context / common pairing | Example flags |
|---|---|
| Prior authorization for new starts is frequently paired with other utilization controls | Common combined flags: 'PA New Starts' with LA (limited access) or QL (quantity limit); EDS may also appear |
| Product | Requirement |
|---|---|
| VERSACLOZ oral suspension 50 mg/mL | Requirements/Limits = ST (step therapy) indicated |
| GLP-1 / oral GLP products | Requirement / Note |
|---|---|
| OZEMPIC (semaglutide) subcutaneous pen-injector | Requirements/Limits = PA New Starts; QL; EDS — prior authorization for new starts noted; no multi-step algorithm shown in excerpt |
| MOUNJARO (tirzepatide) subcutaneous auto-injector and RYBELSUS (oral semaglutide) | Requirements/Limits = PA New Starts; QL; EDS — PA New Starts indicated, explicit step sequencing not provided in excerpt |
| Product | Requirement |
|---|---|
| aliskiren fumarate (listed in cardiovascular agents) | Requirements/Limits = ST (step therapy applies) |
| Specialty / high-cost examples | Requirement / Flag |
|---|---|
| REPATHA (various presentations) — PCSK9 inhibitors | Requirements/Limits = PA New Starts; EDS (management for new starts and edits) |
| RADICAVA ORS, SKYCLARYS, AUSTEDO and other specialty CNS agents | Requirements/Limits = PA New Starts; LA; QL as listed |
| Multiple other specialty oral oncology agents | Requirements/Limits = PA New Starts; LA (limited access) often present |
| Product | Requirement / Example |
|---|---|
| PANRETIN external gel 0.1% | Requirements/Limits = PA New Starts (prior authorization required for new starts) |
| Product / Example | Implication |
|---|---|
| ATTRUBY and similar specialty/genetic disorder therapies (examples in document) | Requirements/Limits include 'New Starts' or 'LA' which imply origin or access restrictions for coverage; explicit step therapy algorithms not shown in excerpt |
| Product examples | EDS implication |
|---|---|
| Desmopressin, estradiol patches, selected testosterone formulations (examples listed) | Requirements/Limits = EDS — indicates formulary edits/step requirements apply; prescriber documentation or prior use of preferred alternatives may be required |
Quantity Limits (QL) — Examples and Line Items
Site-of-Care and Pharmacy Limitations
ARIKAYCE: PA and limited access (may require specialty pharmacy)
ARIKAYCE is marked 'PA; LA', indicating limited access and PA requirements that may restrict dispensing to specialized pharmacies or infusion/authorized providers; coordinate with the plan or specialty pharmacy for appropriate site‑of‑care dispensing.
- LA indicates the drug may be available only at certain pharmacies — consult the Pharmacy Directory or Member Services
Diclofenac gel: specialist exemption for PA
Diclofenac gel is listed with PA but the formulary specifically notes that prior authorization is not required for dermatologists or oncologists; when applicable, document the prescriber's specialty with the claim or PA request.
Site‑of‑care and administration setting may affect PA and billing
Some IV/infusion products and hospital/clinic‑administered therapies (for example CLINIMIX, PLENAMINE, PROLASTIN‑C) carry BD/PA/LA flags and tiering — site‑of‑care restrictions or billing designations may apply and prescribers should confirm appropriate administration setting and documentation.
- BD indicates a potential Part B/Part D determination; consult plan guidance for site‑of‑care billing
- PROLASTIN‑C and CLINIMIX show PA/LA/BD designations — coordinate with the plan for authorization and site‑of‑care
Legend and Glossary
Background / Scope
The formulary is organized by medical condition and drug class; each drug line shows its formulary tier and may include utilization controls such as Prior Authorization (PA), Quantity Limits (QL), and Step Therapy (ST). Providers should follow the Requirements/Limits flags shown on each line when seeking coverage.
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