Independent Health Drug Formularies are lists of drugs that are covered under your plan. Formulary drugs are medications recommended by the Independent Health Pharmacy & Therapeutics Committee. These drugs are selected based on a quality evaluation of safety, effectiveness, unique qualities and costs.
Independent Health's Drug Formulary I
The following information applies to plans offered through large group. Check your summary of benefits to ensure this formulary (Drug Formulary I) is associated with the plan offered to you by your employer prior to using your prescription drug benefit.
Independent Health's Drug Formulary II
The following information applies to plans offered through the NY State of Health: The Official Health Plan Marketplace – for individuals through the Individual Marketplace. This information also applies to Independent Health plans offered to individuals directly, not through the marketplace. Check your summary of benefits to ensure this formulary (Drug Formulary II) is associated with your plan prior to using your prescription drug benefit.
View the 2023 Independent Health Drug Formulary II
Independent Health's Drug Formulary III
The following information applies to small group plans available directly from Independent Health, as well as those offered through the NY State of Health: The Official Health Plan Marketplace – for small businesses through the Small Business Marketplace. Check your summary of benefits to ensure this formulary (Drug Formulary III) is associated with your plan prior to using your prescription drug benefit.
View the 2023 Independent Health Drug Formulary III
Independent Health’s FEHB Drug Formulary
The following information applies to plans offered through Federal Employees Health Benefits (FEHB). Check your summary of benefits to ensure this formulary is associated with your plan prior to using your prescription drug benefit.
Independent Health’s MediSource and Child Health Plus Formulary
The following information applies to Independent Health’s New York State Sponsored Plans, Child Health Plus and MediSource (Medicaid). Check your summary of benefits to ensure this formulary is associated with your plan prior to using your prescription drug benefit.
Essential Plan Formulary
The following information applies to plans offered through the Essential Plan. Check your summary of benefits to ensure this formulary is associated with your plan prior to using your prescription drug benefit.
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:
Certain drugs have a quantity limit, which means we’ll provide coverage only up to the limit specified:
Important pharmacy benefit information for MediSource and Child Health Plus:
- Please use your Independent Health ID card at the pharmacy to receive your prescriptions, not your Medicaid benefit card.
- You must use a pharmacy that accepts Independent Health coverage. If your pharmacy does not take Independent Health, you may need to get new prescriptions from your doctor to take to a pharmacy that takes Independent Health.
- Not every drug will be covered on the formulary. If a medication is not covered, you or your pharmacist may need to talk to your doctor about changing to a medication that is on our formulary.
- On October 1, 2021, drugs used to treat opioid dependence and opioid reversal agents covered on our formulary will follow New York State Medicaid’s statewide medication-assisted treatment (MAT) formulary. View this formulary online.
Pharmacy Coverage for Vaccines for Independent Health’s Medicaid Managed Care Plans: Children (VFC-Eligible) Members And Adults (Non-VFC Eligible) Members
The New York Vaccines for Children (VFC) Program provides no-cost vaccines to underserved populations of children in New York state. To qualify, children must be New York residents who are under 19 years old and are:
- Enrolled in Medicaid, or
- Underinsured, or
- Uninsured, or
- American Indian or Native Alaskan
Any child who is eligible for this program should receive the vaccines through the VFC, including children who are enrolled in Medicaid Managed Care programs.
As the vaccine is provided to these members at no cost, Independent Health will not reimburse a pharmacy for the cost of the vaccine. We will, however, reimburse a pharmacy an administration fee when administering the vaccine to one of our members.
To receive the administration fee, pharmacies should bill the NDC for the vaccine as they normally would for our other members. Independent Health will return a response with no reimbursement for the vaccine, but we will include a separate administration fee.
Medicaid Managed Care Members
Independent Health’s Medicaid managed care members can be identified by their BIN number (016557) and by their ID number, which consists of their Medicaid CIN#, preceded by the letter “D”.
If a pharmacy has any questions regarding identifying a VFC eligible member or how to bill the claim, please call our Pharmacy Help Desk at 1-800-993-9898.
How to become a VFC Provider
Pharmacies are able to sign up to become a VFC provider. There are a number of requirements, including inspections, which are handled through the New York State Department of Health (for pharmacies located outside of New York City).
For additional information on the VFC Program, including how to become a provider, visit the VFC website.
Vaccine Coverage for Adult Members (non-VFC Coverage)
For Independent Health’s Medicaid managed care members aged 19 and over, pharmacies should bill the NDC number for the vaccine administered. As the vaccines are not provided at no cost by the VFC program to the pharmacy for these members, the pharmacy will receive reimbursement for both the cost of the vaccine and the administration fee
Medication Assisted Therapy (MAT)
As of October 1, 2021, medications to treat opioid dependence and opioid reversal agents covered on our formulary follow NYS Medicaid’s statewide MAT formulary. You can view this formulary by visiting this website: https://newyork.fhsc.com/providers/mat.asp
Guidance for Pharmacies Billing Non-Enrolled Prescriber Exceptions
The 21st Century Cures Act requires that all Medicaid Managed Care (MMC) plan providers are enrolled in their respective state’s Medicaid program. As part of this requirement, all MMC plans in New York state will reject pharmacy claims written by a non-enrolled provider or filled by a non-enrolled pharmacy. Interns, residents, and foreign physicians in training are exempt from this enrollment requirement. Members in Independent Health’s MediSource and MediSource Connect plans will be impacted by this limitation, as their claims will not adjudicate.
Prescriptions written by a non-enrolled prescriber will reject when a pharmacy submits a claim to Independent Health. The following rejection message will display: “Prescriber not enrolled in Medicaid pgrm”. Pharmacies may override the claim to pay by entering submission clarification code (SCC) “55” (or “42” if your system does not allow use of “55”). This override should be used only in the following situations:
- The prescriber writing the prescription is exempt from the enrollment requirement as they are an intern, resident, of foreign physician in training.
- The medication was written for an urgent/emergent situation where waiting to see an enrolled provider could further worsen the member’s condition.
- There are no enrolled providers able to service the member for the condition/service that the member is being treated by the non-enrolled provider for.
Prescriptions filled by a non-enrolled pharmacy will reject when a pharmacy submits a claim to Independent Health. The following rejection message will display: “Pharmacy Participation Not Established”. If a non-enrolled pharmacy requires an override for the claim, they will need to contact our Pharmacy Help Desk at (800) 993-9898 to obtain an override. Overrides will only be provided in the following situations:
- The member is filling the prescription at a non-enrolled pharmacy due to an urgent/emergent issue.
- There are no enrolled pharmacies that can service the member for the prescription/service that the non-enrolled pharmacy is providing.
If pharmacies have any additional questions or need assistance in billing a claim for a non-enrolled prescriber or pharmacy, please call our Pharmacy Help Desk at (800) 993-9898.
Guidance for Practitioners Billing Medications
Per New York State Education (NYSED) Law, Article 137 §6807, practitioners who are authorized to prescribe may dispense certain classes of medications to patients directly out of their office. When dispensing, practitioners must maintain records for the dispensing and follow all state and federal regulations and Independent Health policies.
To bill medications dispensed to Independent Health members, use the following HCPCS code and the corresponding NDC for the product dispensed:
J8999 – Rx Drug Oral Chemotherapy
J8499 – Rx Drug Oral Non-Chemotherapy