Independent Health Essential Plan Formulary Coverage

Formulary Coverage Criteria and Controls

Formulary coverage criteria and controls

Summary of formulary design, tiering, utilization controls and operational rules.

Three-tier formulary: Tier 1 (lowest member cost-share), Tier 2 (higher), Tier 3 (highest).

Formulary may change during the year; drugs may move tiers or be removed and unsafe drugs are removed immediately with member notification per requirements.

Prior authorization (PA) is required for certain medications; PA-coded drugs are listed on the formulary and requests must be submitted by the provider to Independent Health for approval.

Step therapy (ST) applies to some drugs and requires trying specified medications first before covering another drug for the same condition.

Quantity limits (QL) may apply to certain medicines; QL markings on formulary indicate numeric or package-based limits which take precedence over pre-packaged limitations when specified.

Specialty medications (SP) are managed through Reliance Rx and may require specialty pharmacy dispensing; some specialty medicines are limited distribution drugs (LDD) available only at designated pharmacies.

Affordable Care Act preventive drugs are marked 'ACA' and have no member cost-sharing subject to USPSTF recommendations and plan renewal rules.

Maintenance medications (MM) may be eligible for up to a 90-day supply where indicated on the formulary.

Insulin has a maximum cost-share per 30-day supply; refer to the member contract for details.

Over-the-counter (OTC) coverage: Plans #3 and #4 may cover Medicaid‑approved OTC drugs with a prescription; member cost‑sharing depends on plan.

Coverage is limited to medically‑accepted indications based on FDA labeling and NY State Medicaid exclusions; non‑FDA‑approved and FDA‑excluded drugs are not covered.

Compounded prescriptions must be prepared by a participating pharmacy, include at least one prescription component, follow compounding policy, and are subject to the compounded‑medication rules (tiering and PA thresholds).

Preferred diabetic supplies and CGM devices are identified as preferred and generally do not require prior authorization when used per formulary rules; non‑preferred sizes/products may require PA and numeric quantity limits apply to strips/sensors.

Compounded medications coverage criteria (partial)

Coverage and PA rules for compounded prescriptions.

Compounded prescription must be prepared by a participating pharmacy and contain at least one prescription component.

Dispensing pharmacy must submit for prior approval when required and compounds are covered in accordance with the Compounding Medication Products Policy.

Cost threshold

If total compound cost is $200 or less and all other requirements are met, prior authorization is not required.
If total compound cost exceeds $200, prior authorization is required.

When covered, compounded prescriptions are available at Tier 2 cost‑share; bulk products and powders are excluded from coverage.

Diabetic supplies and CGM coverage (partial)

Preferred diabetic supplies, CGM devices and numeric quantity limits.

Embecta needles and syringes are the preferred needle/syringe products; commonly used insulin sizes are covered while other sizes may require prior authorization.

FreeStyle glucose meters, lancets, test strips, and supplies are preferred and do not require prior authorization; Abbott will provide one glucose meter per member with limited quantity (one per plan year).

Diabetic test strips quantity limits

Non‑insulin dependent diabetics: test strips limited to a maximum of 100 per 30 days.
Insulin dependent diabetics: test strips limited to a maximum of 300 per 30 days.

Continuous glucose monitor sensors — FreeStyle Libre series: up to two sensors per 28‑day supply or six sensors per 84‑day supply subject to formulary limits; Dexcom G6/G7: up to three sensors per 30‑day supply or nine sensors per 90‑day supply; Dexcom transmitter: one wireless transmitter every 90 days; some Dexcom sensors include built‑in transmitter; one receiver device per plan year.

Exclusions and restricted coverage (partial)

Categories and circumstances where drugs, devices or services are excluded or limited.

Medications used for cosmetic purposes are excluded from coverage.

Medical devices other than the listed diabetic supplies and inhaler spacers are excluded from coverage.

Medical foods (except those to treat inborn errors of metabolism such as PKU) are excluded from coverage.

Medications for sexual or erectile dysfunction are not covered.

Fertility and growth hormone limitations

Up to three cycles of select fertility medications (bromocriptine, clomiphene citrate, letrozole and tamoxifen) are covered; prior authorization may be required.

Formulary tiers and utilization notes (partial)

Formulary entries are presented with tier assignments and notes that modify coverage (examples).

Drugs are assigned to tiers (1–3 shown in the formulary) and many entries include utilization notes (e.g., PA, ST, OTC) that affect coverage and member cost‑share.

Example product list

Examples of listed products in this excerpt include meloxicam, naproxen, oxaprozin, butalbital‑apap‑caffeine, ORENCIA, OTEZLA, fentanyl patches, hydrocodone formulations and morphine products.

Formulary flags and controls (partial)

Common formulary flags and handling notes used across entries.

Entries include numeric tiers (1–4 or blank) and utilization flags such as PA (prior authorization), QL (quantity limit), SP (specialty pharmacy), LDD (limited distribution), MM (maintenance), AL (age limit) and ST (step therapy).

PA qualifiers

Some PA notes are qualified by duration (e.g., PA required for duration greater than 14 days) or by specialty (e.g., PA except Neurology, PA except Psychiatry, PA except Dermatology/Optometry/Ophthalmology).
Certain biologics and injectables are marked 'PA; SP' indicating both prior authorization and specialty pharmacy dispensing are required.

'QL' markings indicate quantity limits may apply and package‑based limits may be overridden by a listed formulary QL when specified.

TOC coverage entries (partial)

Table‑of‑contents style entries showing drug/formulation, tier and shorthand notes for utilization management.

TOC entries list drug/formulation lines with a Tier field and Notes field; Notes commonly include PA, QL, ST, AL, OTC, MM and SP which modify coverage and may trigger prior authorization or other controls.

Representative TOC examples

Examples in the TOC include antiepileptics (gabapentin, lacosamide, lamotrigine) annotated with Neurology, QL, PA flags; FETZIMA listed with ST; pregabalin entries with PA or PA except Psychiatry notes.

When TOC notes include LDD or SP, the item may require specialty dispensing or limited distribution channels.

Formulary indicators (TOC)

How coverage stance is indicated in the table of contents.

Coverage stance for each listed product is indicated by the numeric Tier (1–4 or blank) plus note flags adjacent to the drug name; the Tier governs member cost‑share while note flags indicate utilization controls.

Common restriction flags shown in the TOC include: PA, QL, ST, MM, SP, LDD, AL, I (injectable), OTC, ACA and SUD.

Sample formulary entries with coverage modifiers

Sample formulary lines demonstrating tier and notes that modify coverage.

Some sample entries illustrate combinations of tier and notes that affect coverage (e.g., cetirizine chewable listed with OTC/ACA; chlorpheniramine with PA; desloratadine with PA/AL/attestation; benazepril‑HCTZ with PA/LDD/PA exceptions; rifampin with PA/SP/AL; multiple antineoplastics with PA/SP/LDD).

These sample entries show how PA, SP and LDD notes often accompany higher‑tier or specialty products and can trigger prior authorization, specialty dispensing and limited distribution handling.

Observed coverage stance entries (excerpt)

Observed formulary entries illustrating tiered coverage with utilization controls.

Observed entries for oncology and other specialty therapies (e.g., COMETRIQ, LENVIMA, XPOVIO) are assigned to Tier 3 and carry notes such as PA, LDD, SP and sometimes MM, reflecting prior authorization, limited distribution and specialty handling.

Some supportive agents (e.g., leucovorin) are Tier 1 with no special notes, demonstrating heterogenous tiering across product classes.

Formulary Table of Contents coverage indicators

Table of contents indicators for coverage controls across the formulary.

TOC lines across categories consistently pair Tier values with utilization notes (PA, QL, LDD, SP, MM, ST, AL, ACA) indicating that coverage and access depend on both tier placement and the listed controls.

Specific clinical coverage criteria are not shown in these TOC extracts; the flags signal when additional authorization or limits apply.

Coverage stance for listed formulary items

Coverage stance summary for selected product lines.

Listed cardiovascular, pulmonary and specialty agents are shown with tiers and Notes that may require PA, LDD, QL, AL, SP or MM; these controls determine coverage scope and provider actions required.

When Notes indicate PA or specialty/LDD, prescribers must follow prior authorization and designated dispensing procedures to obtain coverage.

Formulary TOC coverage stance (partial)

Partial TOC extract showing tier and Note annotations without full criteria.

This TOC extract lists multiple products with Tier and Notes columns; where Notes include 'PA' or other flags, coverage is subject to utilization management but specific clinical criteria are not provided in this partial extract.

Topical and related formulary entries (partial)

Topical and related formulary entries showing tiering and utilization notes.

Topical agents are listed with Tier values and Notes; many topical and dermatology products include PA, PA except specialty qualifiers, QL or LDD notes that modify coverage and require provider action.

Some topical entries are OTC and may follow different coverage/billing rules; PA exceptions are sometimes limited to dermatology or pediatric specialties.

Formulary tier and utilization note entries (partial)

Formulary listing examples and utilization note patterns in a mid‑section extract.

Multiple items in this segment show Tier assignments with associated Notes indicating PA, LDD, SP, QL, AL or OTC; these notes affect coverage and dispensing channels.

Representative examples

VALCHLOR EXTERNAL GEL listed with PA; LDD; other topical agents listed with PA or SP notes.
PENTASA oral capsule shown with PA; SP; AL in another line indicating specialty and age‑related limits.

Where Notes include LDD or SP, specialty pharmacy or limited distribution processes apply for dispensing and prior authorization.

Formulary coverage flags and implications

How tier assignments and coverage flags affect reimbursement and access.

Tier assignment (1–4 or blank) governs member cost‑share; entries annotated with 'PA' indicate prior authorization is required for coverage unless an exception is noted.

Utilization flags and implications

'QL' indicates quantity limits that restrict the amount dispensed within a time period.
'OTC' designations reflect over‑the‑counter status which can change coverage/billing rules and may require a prescription for plan coverage.
'SP' and 'LDD' indicate specialty pharmacy handling or limited distribution which affect where and how the drug can be obtained.

Coverage stance by product group

Coverage stance by product group (minerals, multivitamins, ophthalmics and related items).

Minerals, electrolytes and multivitamin entries show mixed tiering with Notes including OTC, PA, QL and LDD for prescription or specialty formulations.

Some OTC vitamins/minerals are listed as OTC and may be subject to different coverage rules; prescription‑strength or limited‑distribution versions may require PA or specialty handling.

Ophthalmic agents are extensively listed with tiers and utilization controls; cyclosporine ophthalmic emulsion explicitly carries 'PA; PA except ophthalmology and optometry; QL' and other ophthalmic agents may have PA, SP or LDD notes.

Coding, Quantity Limits, and Code-Level Notes

Covered HCPCS / Product CodesHCPCSCovered

A9276	Sensor, transmitter and/or receiver for continuous glucose monitoring system
A9277	Sensor glucose test
E2100	Supply allowance - glucose monitor supplies (example code)

Covered NDC / DevicesNDCCovered

Dexcom G6	Dexcom G6 continuous glucose monitoring sensors/transmitters (device-level grouping)
Dexcom G7	Dexcom G7 continuous glucose monitoring sensors/transmitters (device-level grouping)
FreeStyle Libre	FreeStyle Libre sensors/receivers (device-level grouping)
FreeStyle Libre 2	FreeStyle Libre 2 sensors/receivers
FreeStyle Libre 3	FreeStyle Libre 3 sensors/receivers

Formulary / Neutral Entriesmixed

Formulary product entries and tiers listed elsewhere; specific CPT/HCPCS/NDC codes not shown in excerpt

Formulary - Placeholder (no billing codes in excerpt)mixed

Formulary product entries (names/tiers/notes) present in source but CPT/HCPCS/NDC codes not provided in excerpt

Formulary Entries without Codesmixed

Placeholder for formulary entries without CPT/HCPCS/NDC codes in this excerpt

Formulary Entries (no codes) - placeholdermixed

Neutral placeholder for entries without billing codes in the provided segment

Formulary - No Codes Listedmixed

Additional formulary entries referenced; codes not included in excerpt

Formulary Codes Absent - Chunk 72mixed

Codes absent in this segment — placeholder

Formulary Names/Tiers/Notes - Placeholdermixed

Formulary entries (names/tiers/notes) referenced; no billing codes in excerpt

Drug Listing - No Billing Codes Shownmixed

Drug listing referenced in source; CPT/HCPCS/NDC codes not provided in excerpt

Formulary Tiering Placeholdermixed

Formulary tiering excerpt present; specific billing codes not shown

Formulary Drugs - No Code System Shownmixed

Formulary drug entries referenced without explicit code system in excerpt

Formulary Drug Entries (partial) - zero-code placeholdermixed

Partial entries present; no CPT/HCPCS/NDC codes included in source excerpt

Formulary Entries - No Codes Presentmixed

Neutral placeholder for formulary entries lacking billing codes in this segment

Formulary Entries - No Procedure/Diagnosis Codesmixed

Formulary entries without procedure/diagnosis codes in this excerpt

Formulary Entries - No Codesmixed

Another neutral placeholder for code-less formulary entries

Formulary Product Listings - No CPT/HCPCS/NDCmixed

Product listings present; billing codes not shown in provided excerpt

Actions Required by Prescribing Providers

Prior Authorization

Medical Exception

If a prescriber determines a non-formulary medication is medically necessary, they may submit a medical exception request to Independent Health's Medical Director. The provider must complete and fax the medical exception form to Independent Health's Prior Authorization Department for review. If approved, the drug will be covered at the Tier 3 member cost-share.

Provider must submit completed medical exception form to Independent Health's Prior Authorization Department.
Approved medical exceptions result in coverage at Tier 3 member cost-sharing.

Prior Authorization

Prior Authorization Required

Independent Health requires prior authorization (PA) for many medications. Prior authorization requests must be submitted by the prescribing provider and approved by Independent Health before coverage is provided for drugs annotated with PA in the formulary.

PA is required for many products listed in the formulary and TOC entries (see Notes = PA).
Some PA requirements include specialty, duration, oncology and quantity-limit qualifiers — e.g., PA required for durations >14 days or when written by Oncology.

Definitions and Formulary Key

Generic / Biological / Biosimilar (definitions)

GenericGeneric drugs have the same active ingredient as the brand name drug and are typically listed in lower case on the formulary.

Biological productBiological products are made in a more complex way than conventional drugs; biosimilars are analogous alternatives for biologics.

BiosimilarBiosimilars are FDA‑approved alternatives to biological products and generally perform similarly at lower cost.

Formulary key and note flags

Formulary key (common flags)PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits; SP = Specialty Pharmacy; LDD = Limited Distribution Drug; ACA = Affordable Care Act preventive; AL = Age Limit; DF = Dental Formulary; OTC = Over‑the‑counter; MM = Maintenance Medication.

Usage context

OpenPayer

Independent Health 2026 Essential Plan Drug Formulary (introduction)

Formulary Coverage Criteria and Controls

Coding, Quantity Limits, and Code-Level Notes

Actions Required by Prescribing Providers

Definitions and Formulary Key