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An Introduction to Independent Health’s2021 FEHB Drug FormularyNote: If you are reading a printed version ofthis drug formulary, content may have beenupdated since it was last printed. For themost up-to-date information, please visitindependenthealth.com.Independent Health members benefit when theirhealth care providers use the formulary becauseall medications included are selected due to theireffectiveness and safety. Use of a formulary alsoensures that premiums are kept to a minimum.The cost of each medication on the formulary isbalanced with its effectiveness, which means thatmedications are not included on the formulary justbecause they are inexpensive; effectiveness ismore important that the price of the medication. Ifa medication is not capable of achieving thedesired effect, then the price of treating an illnessor condition increases because other therapiesmust be used. Likewise, there are expensivemedications that have not been proven to be anymore effective than less costly alternatives.Since 1996, all prescriptions for IndependentHealth members have been written from theformulary in order to qualify for coverage.When health care providers write aprescription for Independent Health members,they consult the formulary and select themedication needed. Occasionally, membersneed a medication that is not on the formulary.In cases when it is medically necessary for apatient to have a medication that is notincluded on the formulary, health careproviders are encouraged to request a medicalexception from Independent Health’s MedicalDirector. The health care provider will need tocomplete a medical exception form and fax itto Independent Health’s Prior AuthorizationDepartment, who will review the details of thecase.To obtain a medication that is non-formulary, yourhealth care provider is encouraged to submit aprior authorization request for coverage throughthe exceptions process. If the request is approved,that particular medication will be covered at yourTier 3 copayment/coinsurance level.All medications listed on the formulary will beavailable to you and you will be responsible forpayment of the copayment/coinsurance asreferenced in this document. You will note on thelist that a medication’s copayment/coinsurance isassigned to a tier. How this affects yourcopayment/coinsurance depends upon whatprescription plan you have. Independent Healthreserves the right to modify the copay/tier of aparticular medication as necessary. For example,when a generic equivalent becomes available fora covered brand-name medication, the brandname medication becomes non-formulary (notcovered) and will be covered only if approvedthrough the medical exception process.Independent Health reserves the right to changethe duration of an approved prior authorizationthrough the medical exception process, includingbut not limited to the termination of a previouslyapproved authorization. Approval of a priorauthorization request does not itself guaranteepayment; payment is made based on plan/benefitdesign. The generic equivalent medication will becovered in Tier 1 or Tier 2. Because of this, theactual copayment/coinsurance paid may notmatch the copayment/coinsurance tier levels aspublished in this document. To determine whichprescription plan you have, please refer to yourcontract. If you have further questions, you maycontact Independent Health’s Member ServicesDepartment.Because there are thousands of medications inthe marketplace, not all Tier 3 non-preferredmedications can be listed here. IndependentHealth makes every attempt to provide you withas accurate a listing of medications as possible,however the list of medications and availability ofgenerics can change frequently. Since this listwas created, some medications may have beenadded, while others may have been deleted. Foran updated version of the formulary please visitour website at independenthealth.com.

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. Medications that requireprior authorization are listed with a “PA” in theformulary.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 usuallymeans that an equally effective generic medicationis prescribed 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 or 90 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.Specialty Pharmacy. Specialty medicationsinclude those that are either self-injectable,require special distribution, handling and/or are atlimited supply and certain oral oncologymedications. These medications are restricted todesignated pharmacies such as Reliance Rx.Reliance Rx specializes in providing high-qualityservice for complex chronic conditions such ashepatitis, multiple sclerosis, cancer andrheumatoid arthritis.Along with providing these specializedmedications, Reliance Rx also provides aconvenient way for you to receive themedication, by arranging delivery at no chargedirectly to your home. They can also provide youwith education on the medication you’re taking,refill reminders and even the necessary supplies,if applicable. Specialty medications are listedwith a “SP” on the formulary. Reliance Rx can bereached at 1-800-809-4763.Limited Distribution DrugsSome specialty medications can only be obtainedthrough designated specialty pharmacies due tolimited distribution placed on the medication bythe manufacturer. These medications are listedwith a “LDD” on the formulary.Affordable Care Act (ACA)Preventive ServicesMedications covered under the Affordable CareAct as preventive services are listed with an“ACA” on the formulary. Certain restrictionsmay apply.For some items that come pre-packaged (forexample: tube/container, inhaler device, singledose units, or liquid container), one package sizeis allowed per fill of these items. If a quantity limitis designated on the formulary, this restriction willtake precedence over the pre-packagedlimitations, 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.Specialty MedicationsIn order to add value and accessibility in yourpharmacy benefits, we offer a specializedprescription medication program for certainspecialty medications through Reliance Rx Maintenance MedicationsIndependent Health allows up to a 90-day supplyof certain medications to be filled. Medicationseligible to be filled for a 90-day maintenancesupply are indicated on the formulary with an“MM.”

The first fill of new maintenance medications willrequire a 30-day initial fill to ensure you do nothave any side effects. After the initial 30-daysupply has shown you can tolerate themedication, you can receive future refills for up toa 90-day supply as prescribed.Over-the-Counter (OTC) MedicationsCertain medications listed on the formulary areavailable over the counter. A prescription isrequired for coverage of the OTC products.OTC products that we cover are listed with an“OTC” on the formulary.Preventive with LiabilitySome medications are considered preventive care forthose with qualifying chronic conditions. For deductibleplans where this benefit is applied, you areresponsible for your tiered copayment/coinsuranceduring the deductible phase. These medications arelisted with a “PL” on 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.KeyACA – Affordable Care ActAL – Age LimitDF – Dental FormularyLDD – Limited Distribution DrugsMM – 90-day supplyOTC – Over-the-CounterPL – Preventive with LiabilityPA – Prior Authorization RequiredQL – Quantity Limits ApplySP – Specialty PharmacyST – Step TherapySedative/Hypnotic MedicationsSedative/hypnotic medications are limited for allprescribers except sleep specialists to 14tablets/capsules per month with a maximum of 3fills per 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 the compounded prescriptionwill be available at a Tier 2 copayment/coinsurance. Coverage is provided in accordancewith our Compounding Medication Products Policy.Bulk products and powders are excluded fromcoverage because they are not prescriptionmedication products that are approved undersections 505, 505(j) or 507 of the Federal Food,Drug, and Cosmetic Act.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 thepharmacy, you will pay the lesser of yourdiabetic or pharmacy cost-share. If you obtain your medication at a medicalsupply provider, you will pay your diabeticcost-share.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 with