2019 Medicaid Formulary

An Introduction to Independent Health’s 2019MediSource and Child Health Plus FormularyThe following information applies toIndependent Health’s New York StateSponsored Plans, Child Health Plus andMediSource (Medicaid). Check your summaryof benefits to ensure this formulary isassociated with your plan prior to using yourprescription drug benefit.This dru g formulary lists covered generic andbrand-name drugs covered under our ManagedMedicaid Plans, MediSource and Child HealthPlus. Independent Health makes every attempt toprovide you with as accurate a listing ofmedications as possible. However the list of drugsand availability of generic medications can changefrequently. When a generic medication becomesavailable for a formulary brand-name medication,the generic medication will be covered and thebrand-name medication will become non-formularyand will require prior authorization to be covered.Please discuss any questions you may have aboutthe formulary with your provider.Prior-AuthorizationIndependent Health requires you to get priorauthorization for certain medications. To obtaincoverage for a medication requiring priorauthorization, a prior authorization request formedical exception must be submitted by yourhealth care provider and approved byIndependent Health’s Medical Director.Medications that require Prior Authorization arelisted with a “PA” in the formulary.Step TherapyIn some cases, Independent Health requires you tofirst try certain medications to treat your medicalcondition before we cover another medication forthat condition. Step therapy is a way to help youget the best quality and value from yourprescription medication benefit. This usually meansthat an equally effective generic medication isprescribed before a more expensive brand-namemedication. Step therapy may also ensure that twomedications are used together if they are moreeffective. Medications that require Step Therapy arelisted with a “ST” in the formulary.Quantity LimitationsQuantity limitations may apply to certainmedications. Some medications are covered upto a specific quantity per 30 days. Someexamples of medications with a quantitylimitation are: sumatriptan (generic Imitrex ) andzolpidem tartrate (generic Ambien ). Medicationswith quantity limitations are listed with a “QL” inthe formulary.For items that come pre-packaged (for example:tube/container, inhaler device, single dose units, orliquid container), one package size is allowed perfill of these items. If a quantity limit is designatedon the formulary, this restriction will takeprecedence over the pre-packaged limitations,when applicable.Age RestrictionSome prescription medications are restricted byage due to safety reasons or Food and DrugAdministration (FDA) recommended labeling.Medications with an Age Limit are listed with an“AL” in the formulary.Dental FormularyDrugs covered on our Dental Formulary areavailable when prescribed by a dental provider.Drugs included in our Dental Formulary are listedwith a “DF” on the formulary. Drugs without a “DF”will not be covered when written by a DentalProvider.Limited Distribution DrugsSome specialty medications can only be obtainedthrough designated specialty pharmacies due tolimited distribution placed on the medication by themanufacturer. These medications are listed with a“LDD” on the formulary.

Maximum Daily Dose (MDD)Certain medications are dose limited by amaximum daily dose (MDD) as recommended bythe Food and Drug Administration (FDA) for safetyreasons. Limits may be set by the number oftablets/capsules per day or the total daily dose.Over-the-Counter (OTC) MedicationsCertain medications listed in the formulary areavailable over the counter. A prescription isrequired for coverage of the OTC products.Sedative/Hypnotic MedicationsSedative/hypnotic medications are limited for allprescribers except sleep specialists to 14tablets/capsules per month with a maximum of 3 fillsper year (3 fills/365 days).Compounded Prescription MedicationsCompounded prescriptions (medications that arenot commercially manufactured) must be preparedby a participating pharmacy and contain at leastone prescription component. The dispensingpharmacy is required to submit for prior approvaland when covered, will take the applicablecopayment. Coverage is provided in accordancewith our Compounding Medication ProductsPolicy. Bulk products and powders are excludedfrom coverage because they are not prescriptionmedication products that are approved undersections 505, 505(j) or 507 of the Federal FoodDrug and Cosmetic Act.Diabetic Supplies/MedicationsProducts listed in this section are a covered benefitbased on your plan. Products not listed require priorauthorization. Copayments vary by plan.BD needles and syringes are our preferredneedle/syringe products.OneTouch glucose meters, lancets, test strips, andsupplies are our preferred diabetic supplies and donot require prior authorization.OneTouch will provide a glucose meter to you withno copayment. Quantities are limited to one meterper member. You can obtain a meter by callingLifeScan, Inc. at 1-888-377-5227, offer code289IHA001. Please have your ID number availablewhen you call.Diabetic test strips are limited to a maximum of100 per fill/30 days.Affordable Care Act (ACA)Preventive ServicesMedications listed on the formulary that arecovered as preventive services under theAffordable Care Act may be covered. Certainrestrictions may apply.Lost/Stolen/Damaged Medications andVacation SuppliesReplacement of any lost, stolen or damagedmedications is the responsibility of the member.Vacation supplies are not covered under thisbenefit. Prior authorization cannot be used toobtain early refills for lost, stolen, or damagedmedications; or for extended supplies or vacationsupplies.Emergency Room PrescriptionsEmergency Room prescriptions are limited to a10-day supply.Enteral and ParenteralNutritional FormulasEnteral Nutritional Formula and ParenteralNutritional Formula benefit coverage is based onmedical necessity and prior authorization isrequired. Supplies that are necessary to administerthe specific type of feeding, and maintain thefeeding site are covered. This includes, but is notlimited to: syringes, measuring containers, tipadapters, anchoring devices, gauze pads,protective-dressing wipes, tape, and tube cleaningbrushes.Pharmacy Administered ImmunizationsInfluenza and pneumococcal vaccinations arecovered when administered by licensed pharmacistswho obtain additional certification to administerinfluenza and pneumococcal vaccinations to adults18 years of age and older.

state pharmacy laws. Therapeutic interchangeis not utilized.Additional Formulary Information: Appetite suppressants/weight-loss medicationsare excluded from coverage. Medications used for cosmetic purposesare excluded from coverage. Medical foods other than PKU supplements(which may or may not require a prescription)are excluded from coverage. Prenatal vitamins classified as medical foodsare not covered. Medications used for the treatment of sexual orerectile dysfunction are not covered. Up to three cycles of the following drugs usedto promote fertility are covered:Bromocriptine, Clomiphene Citrate, Letrozoleand Tamoxifen. Prior authorization may beneeded before we will cover these drugs forinfertility. All other drugs used to promotefertility are not covered. Growth hormones are excluded fromcoverage when prescribed for the treatmentof short stature. Medications that are excluded from coverageunder state and/or federal law are not coveredby Independent Health. In order to ensure the safest and mostappropriate care, Independent Health’s drugcoverage criteria is limited to medicallyaccepted indications based on FDA approvedlabeling and guidelines not otherwise excludedfrom New York State Medicaid. Medications listed on the drug formulary ascovered without restriction may require priorauthorization or may not be covered if it isdetermined that they are being used inconjunction with a procedure or treatment notcovered under the member’s Health Contract. Prescriptions are generally limited to a maximumof a 30-day supply per fill. Diabetic Test Strips are limited to a maximum of100 per fill/30 days. FreeStyle Libre continuous glucose monitors andsensors are also available at retail pharmacies, ifmember is concurrently on insulin. Dexcom G6 continuous glucose monitoringsystem covered with concurrent use of bolusinsulin.Cost-share change for diabeticequipment, supplies, and medicationsThe cost share for insulin and oral anti-diabeticmedications will depend on where you obtain thesemedications. This is a change from your currentcoverage: If you obtain your medication at the pharmacy,you will pay your appropriate pharmacy costshare. If you obtain the medication at a medical supplyprovider, you will pay your office visit cost share.KeyAL – Age LimitDF – Dental FormularyLDD – Limited Distribution DrugsPA – Prior Authorization RequiredPR – Prescriber PrevailsQL – Quantity Limits ApplyRF – Restricted to FemalesRM – Restricted to MalesST – Step TherapyXCHP – Not covered for Child Health Plus Medications not recognized by the FDA withouta National Drug Code (NDC) are excluded fromcoverage. Generic substitution is used only as required byAdditional Services for MediSource Members on NextPage