2017 Plan Information

Annual Notice of Change/Evidence of Coverage

Provider and Pharmacy Directory

Formulary and Utilization Management Documents

2017 Prior Authorization Criteria (Individual/Group): Some drugs require you (or your physician) to get prior authorization.

2017 Prior Authorization Criteria (Pharmacy Benefit Dimensions PDP): Some drugs require you (or your physician) to get prior authorization.

2017 Step Therapy Criteria (Individual/Group): In some cases, Independent Health requires that you first try certain drugs to treat your medical condition before we will cover another drug for that condition.

2017 Step Therapy Criteria (Pharmacy Benefit Dimensions PDP): In some cases, Independent Health requires that you first try certain drugs to treat your medical condition before we will cover another drug for that condition.

2017 Formulary Quantity Limits (Individual/Group): Certain drugs have a quantity limit, which means we’ll provide coverage only up to the limit specified.

2017 Formulary Quantity Limits (Pharmacy Benefit Dimensions PDP): Certain drugs have a quantity limit, which means we’ll provide coverage only up to the limit specified.

Multi-Language Insert & Nondiscrimation Notice

Questions? Call Us.
(716) 250-4401 or 1-800-665-1502 (TTY: 1-800-432-1110)

Hours:
October 1 – February 14: Monday – Sunday, 8 a.m. – 8 p.m.
February 15 – September 30: Monday – Friday, 8 a.m. – 8 p.m.
Disclaimers
Independent Health is an HMO, HMO-SNP, HMO-POS, and PPO with a Medicare contract. Enrollment in Independent Health depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider directory may change at any time. You will receive notice when necessary.
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Y0042_C5684 Approved
Last Updated 10/17/2016