OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentIndependent HealthPolicy N/A

Independent Health 2026 Essential Plan Drug Formulary (introduction)

Customize your policy alerts

Sign up for all Independent Health policy alerts

Know when Independent Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This document introduces Independent Health's 2026 Essential Plan drug formulary, explaining tier structure, special program designations, utilization controls (prior authorization, step therapy, quantity limits), specialty and limited distribution arrangements, and coverage rules that affect members and their prescribing providers.

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2026 Essential Plan Drug Formulary (introduction)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for medications marked 'PA' to Independent Health's Prior Authorization Department.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3formulary tiers (Tier 1–3)

90 daysmax maintenance supply

100 / 300test strip limits (non‑insulin / insulin)

$200compounded PA threshold

20+distinct drug headings visible

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.

Policy Summary

PayerIndependent Health

PolicyIndependent Health 2026 Essential Plan Drug Formulary (introduction)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for medications marked 'PA' to Independent Health's Prior Authorization Department.

SourceLink

On This Page

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.

FreeStyle Libre and Dexcom CGM sensors are available at retail pharmacies without prior authorization for members using short‑ or rapid‑acting insulin multiple times daily to control their diabetes.

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.
Growth hormones are excluded from coverage when prescribed for treatment of short stature.

Coverage is limited to medically‑accepted indications based on FDA labeling and NY State Medicaid exclusions; medications not recognized by FDA without an NDC, or prescription medications not FDA‑approved, are excluded.

Generic substitution is used as required by state law; therapeutic interchange is not utilized.

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.

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.

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.
PA may be required even for drugs listed as covered without restriction when used for non‑FDA indications or procedures not covered under the member's contract.

Prior Authorization

Prior Authorization — Specialty & Distribution Notes

Some prior authorization requirements include specialty or prescriber-exception language (for example: “PA except Dermatology”, “PA except Psychiatry”, or “PA except Ophthalmology and Optometry”). Specialty distribution (SP), limited distribution (LDD), and similar flags may modify how PA is applied or where a drug must be obtained.

Entries in the formulary and Table of Contents show specialty exceptions (e.g., PA except Dermatology, PA except Psychiatry, PA except Ophthalmology and Optometry).
Specialty (SP) and Limited Distribution (LDD) flags indicate distribution channel requirements and often accompany PA.
Some drugs are marked Oncology; QL indicating PA applies when prescribed by oncology and quantity limits apply.

Step Therapy

Step Therapy, Quantity Limits, and Other Utilization Controls

Step therapy (ST) and quantity limits (QL) are actively used. ST requires trying specified first-line medications before coverage of alternatives. QL restricts the allowable quantity or fill frequency. Drugs may carry multiple utilization controls simultaneously (PA, ST, SP, QL, LDD, MM, AL, OTC, ACA).

ST entries in the formulary are annotated with “ST”.
QL limits (e.g., test strips limits, sensor quantities for CGMs) are specified in product sections.
Multiple flags may apply together (e.g., PA; SP; QL; LDD).
Some OTC or low-cost items are annotated OTC or ACA which affect coverage and billing.

Prior Authorization

Compounded Medication Prior Approval Thresholds

Compounded prescriptions have specific prior authorization thresholds: compounds costing $200 or less do not require prior authorization if other requirements are met; compounds costing more than $200 require prior authorization. Compounds must be prepared by a participating pharmacy and include at least one prescription component; bulk products and powders are excluded.

Compounds ≤ $200: no PA if all other requirements met.
Compounds > $200: PA required and dispensing pharmacy must submit for prior approval.
Coverage follows the Compounding Medication Products Policy; bulk powders excluded.

Prior Authorization

Diabetic Supplies Prior Authorization Notes

Diabetic supplies have targeted PA and quantity rules. Preferred supplies (FreeStyle glucose meters, lancets, test strips; Embecta needles/syringes) generally do not require prior authorization. Non-preferred sizes, brands, or quantities may require PA. Continuous glucose monitors and sensors (FreeStyle Libre, Dexcom G6/G7) are available without PA for members using insulin multiple times daily, but quantity limits and receiver/transmitter frequency limits apply.

FreeStyle meters, lancets, test strips: preferred; do not require PA.
Embecta needles/syringes: preferred; commonly used insulin sizes covered; other sizes may require PA.
Test strip limits: non‑insulin diabetics — up to 100 per 30 days; insulin‑dependent — up to 300 per 30 days.
CGM sensors: FreeStyle Libre — up to 2 sensors per 28 days (or 6 per 84 days); Dexcom G6/G7 — up to 3 sensors per 30 days (or 9 per 90 days). One receiver per plan year; transmitter replacement limits for Dexcom apply.

Note

Utilization Controls Visible in Table of Contents

Formulary Table of Contents (TOC) entries display utilization-management flags alongside products so providers should consult the TOC and product pages for Notes fields (PA, SP, ST, QL, LDD, MM, AL, OTC, ACA). Many TOC lines explicitly state PA requirements (including qualifiers like duration >14 days or Oncology; QL).

TOC Notes fields show management flags (e.g., “Notes = PA; SP”, “Notes = PA; PA required for duration of greater than 14 days”, “Notes = PA; PA except Psychiatry”).
Providers should review TOC entries for specialty, oncology, LDD and QL qualifiers that affect authorization.
When a TOC entry shows “PA required for duration of greater than 14 days except when written by ...” follow the stated prescriber exceptions.

Prior Authorization

Authorization for Off‑Label or Excluded Uses

Be aware that medications listed as covered without restriction may still require authorization when used for non‑FDA‑approved indications or in conjunction with treatments/procedures not covered under the member's contract. Also, drugs lacking an NDC or not FDA‑approved are excluded from coverage.

Covered‑without‑restriction drugs may require authorization for off‑label uses or non‑covered procedures.
Drugs without NDCs or lacking FDA approval are excluded from coverage.

Prior Authorization

Ophthalmic Prior Authorization Examples

Ophthalmic products provide examples of specialty and prescriber exceptions: cyclosporine ophthalmic emulsion is annotated with “PA; PA except ophthalmology and optometry; QL” and other ophthalmic agents carry PA, QL, SP or LDD flags. Providers in ophthalmology or optometry should note prescriber exceptions and quantity limits when prescribing these agents.

Cyclosporine ophthalmic emulsion: Notes include PA; PA except ophthalmology and optometry; QL; and some formulations also show SP.
Ophthalmic entries frequently include QL or PA qualifiers — check Notes in the TOC and product pages.

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 contextThese shorthand codes appear in the formulary Notes field to indicate utilization management actions and coverage modifiers.

Action for providersProviders should interpret these flags as triggers to review prior authorization, step therapy, quantity limits, specialty dispensing, or age limitations before prescribing/dispensing.

Compounded prescription

Compounded prescription (definition)Medications not commercially manufactured and prepared by a participating pharmacy that contain at least one prescription component; subject to compounding policy and PA threshold rules.

PA requirement summaryCompounds > $200 require prior authorization; ≤ $200 do not require PA if other requirements are met and the dispensing pharmacy submits for approval when covered.

Cost‑shareCompounded prescriptions, when covered, are available at Tier 2 cost‑sharing.

Preferred diabetic supplies

Preferred diabetic suppliesFreeStyle glucose meters, lancets, test strips and supplies are preferred and do not require prior authorization; Embecta needles/syringes are preferred needle/syringe products.

Meter quantity limitAbbott provides one glucose meter per member with no member cost‑sharing (limited to one meter per plan year).

Non‑preferred sizesOther sizes or non‑preferred diabetic supplies may require prior authorization.

Utilization control abbreviations (summary)

PA — Prior AuthorizationPA indicates prior authorization is required for coverage of the listed product unless an exception is noted (e.g., 'PA except dermatology').

QL — Quantity LimitQL indicates that quantity limitations apply to the product as shown in the formulary Notes field.

SP — Specialty PharmacySP flags indicate the product may require specialty pharmacy handling or distribution.

Other abbreviationsAdditional shorthand used includes LDD (limited distribution), AL (age limit), ST (step therapy), MM (maintenance meds), OTC, ACA, DF and DF/DF flags in Notes fields.

Common note code definitions

PA (short form)PA = Prior Authorization; used in notes to indicate prior authorization is required for certain drugs or durations.

LDDLDD = Limited Distribution Drug; indicates restricted distribution channels listed in Notes.

SPSP = Specialty Pharmacy; indicates specialty handling or channel may be required.