List of Covered Drugs (Drug List) — HealthPartners MSHO
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Defines which prescription, over-the-counter, and non-drug products are covered by HealthPartners MSHO, explains member rights and administrative rules (prior authorization, quantity limits, step therapy, exceptions, transitions) and who to contact for assistance. Applies to HealthPartners MSHO members.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage conditions
Covered when ALL of the following are met:
Transition policy
Transition supply rules:
If prescription is written for fewer days, multiple refills may be allowed to reach up to 30 days.
Applies regardless of new member status; transition policy cannot be used for non‑Part D drugs or out‑of‑network drugs unless out‑of‑network access applies.
Formulary coverage entries
Coverage listing by product with utilization annotations; each product line indicates coverage tier and any management actions.
Refer to individual formulary lines for product‑level flags and QL values.
Formulary coverage with utilization controls
Drugs listed are covered under the formulary with utilization controls; coverage is conditioned on meeting PA and other program rules where indicated.
Detailed clinical criteria for PA or NM are not contained in these formulary lines; providers must follow the plan's PA process when PA is flagged.
General formulary coverage entries
Covered drugs and coverage-related flags listed; coverage may be subject to PA, QL, or NM designations shown per product.
Individual coverage decisions depend on meeting the PA, QL, or NM requirements shown for each product.
Drugs may be removed from the List of Covered Drugs at any time if the plan learns they are not safe or if they are withdrawn from the market. When a drug is removed for safety reasons or taken off the market, HealthPartners MSHO will stop coverage for that drug immediately.
Certain formulary line entries are annotated with the code NM to indicate they are Non‑Mail Order and therefore not eligible for the plan's extended mail‑order supply option. Mail order fills are available for up to a 100‑day supply except where a product is marked NM.
Some products and formulations shown in the drug tables carry an NM designation in the 'Necessary actions, restrictions, or limits on use' column. In these listings NM denotes that the product may be considered Not Medically Necessary or otherwise restricted under plan rules for the specified formulation, and coverage will follow the plan's clinical review processes as noted in the formulary rows.
Entries that list both PA and NM (for example ARIKAYCE, linezolid oral suspension, SIRTURO, TOBI PODHALER) indicate the product requires prior authorization and also has a Not Medically Necessary or special review designation for the listed formulation. Providers must submit PA documentation where PA is shown; items marked NM may be denied or require additional adjudication.
Some entries are designated B/D (benefit/medical) or paired with B/D PA, meaning coverage and authorization may follow medical‑benefit processes rather than standard pharmacy benefit rules (examples include cyclophosphamide entries labeled B/D PA; ONC). In such cases medical‑benefit billing and PA procedures apply.
Within the provided excerpts there are no standalone, explicit exclusion statements beyond the per‑product flags and notes. The document refers readers to the formulary key (page I‑11) for symbol and abbreviation meanings.
Multiple formulary rows show NM next to specific products or formulations (for example EPIDIOLEX oral solution and certain rufinamide entries). Where NM appears with or without PA, the product is listed as not medically necessary for that formulation unless any stated PA or other conditions are met.
Several formulary entries are marked NM (Not Medically Necessary) for particular strengths or products (examples include dimethyl fumarate 240 mg and fingolimod 0.5 mg). These NM flags identify formulations that the plan considers not medically necessary in the listed context and subject to denial unless criteria or exceptions apply.
Some biologic and specialty products carry an NM designation (for example COSENTYX, STELARA, ustekinumab and eltrombopag formulations). The NM flag indicates potential non‑coverage or special clinical adjudication for the listed presentation; specific clinical NM criteria are not provided in the excerpted lines.
No additional exclusion language is included in these chunks; the document directs readers to the formulary abbreviations page (page I‑11) for definitions of the table symbols and codes.
If a drug requires prior authorization (PA) and PA is not obtained before dispensing, HealthPartners MSHO may not cover the drug. Providers and prescribers should follow the plan's PA process when the formulary line lists PA.
Numerous specific products are annotated with NM in the formulary rows across the tables (examples include multiple antiretroviral combinations and selected other agents). The listing shows the NM marker at the product/strength level but does not provide the underlying clinical rationale in these excerpts.
Some products have NM noted in the 'Necessary actions, restrictions, or limits on use' column alongside other controls (for example ARIKAYCE, IMPAVIDO, linezolid oral suspension). When NM appears with PA, the product requires prior authorization and may also be considered not medically necessary for the listed formulation unless approved by the plan.
Several drugs throughout the listing are flagged NM (not medically necessary) for specific formulations or strengths. The table entries show the presence of NM but the detailed criteria or clinical justification for those NM determinations are not included in these chunks.
Specific formulary entries marked NM indicate the plan considers those strengths or formulations not medically necessary unless prior authorization or other conditions are met (examples in the listing include EPIDIOLEX, rufinamide suspension/tablet and vigabatrin entries where PA and/or NM are shown).
Multiple listed drugs and strengths across the formulary are explicitly flagged NM in their rows (for example some glatiramer and dimethyl fumarate presentations). These flags signify non‑coverage or special review for those listed uses or presentations.
The formulary shows specific products marked NM (for example some long‑acting injectable antipsychotics and select oral specialty drugs). Where NM appears, the plan may deny coverage for that presentation unless an approved exception or PA is granted.
Several biologic and specialty agents are marked NM in the table (examples include USTEKINUMAB/STELARA entries). When NM appears with PA and QL, the product is subject to prior authorization, medical‑necessity review, and any stated quantity limits before coverage will be approved.
Lines annotated with NM for selected products (for example certain eltrombopag presentations and some biologics) imply that the plan considers those uses not medically necessary under the standard formulary; the excerpt does not include the plan's full NM clinical criteria.
Coding and Supply Limits
| PA | Prior Authorization Required |
| QL | Quantity Limit |
| BvD | This drug could be covered as a Part B or a Part D Benefit |
| ST | Step Therapy Required |
| LA | Limited Access Drug - available only at certain pharmacies |
| NM | Non-Mail Order Drug - not eligible for 100-day mail order |
| V | Vaccines - Part D vaccines at no cost |
| IN | Covered insulin drugs |
| ONC | Oncology medications |
| N/A (drug-level entries) | Multiple drug-specific entries listing drug name, strength/form, tier cost ($0 - $12.65 Tier 1 shown for many), and per-drug 'Necessary actions, restrictions, or limits on use' flags such as PA, NM, QL, B/D. |
| Formulary ID: 26132 | Formulary identifier repeated in this section |
| No codes listed |
| Formulary ID: 26132 | Formulary identifier repeated in multiple chunks |
| Formulary ID: 26132 | Formulary identifier shown in multiple sections of this excerpt |
Provider Actions and Requirements
Obtain prior authorization when listed
Some drugs on the Drug List require prior authorization from HealthPartners MSHO before a prescription can be filled; HealthPartners MSHO may not cover the drug if prior authorization is not obtained.
- Obtain PA before dispensing when a drug entry lists 'PA' in the formulary row.
Check formulary requirement codes on each product
The formulary uses requirement codes to indicate management actions: PA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; NM = Non‑Mail Order / Not Medically Necessary; LA = Limited Access; BvD = Part B/Part D; IN = Insulin; ONC = Oncology.
- Check the 'Necessary actions, restrictions, or limits on use' column for these codes on each product line.
PA required for specific listed drugs (e.g., MAVYRET, ARIKAYCE, CAYSTON)
Certain listed products are marked 'PA' on their formulary lines (examples include MAVYRET pellets/tablet, PREVYMIS, TEFLARO, ARIKAYCE, CAYSTON, XIFAXAN, DIFICID, and various others), indicating prior authorization is required for those products.
- Do not dispense without an approved PA when the product line shows 'PA'.
- Examples shown in the drug list include MAVYRET (PA; NM; QL), ARIKAYCE (PA; NM), CAYSTON (PA; LA; NM), and XIFAXAN (PA).
Obtain PA when 'PA' appears in the formulary row
Prior authorization is required for any product whose formulary row lists 'PA' in the 'Necessary actions, restrictions, or limits on use' field; obtain PA before dispensing when PA is indicated.
- Examples include ARIKAYCE INHALATION SUSPENSION 590 mg/8.4 mL and many antineoplastic agents noted with PA.
- Follow the plan's PA process prior to filling.
Submit PA for oral antineoplastic/immunosuppressant agents
Many oral antineoplastic and immunosuppressive agents are annotated with 'PA' (often paired with ONC and NM flags); claims for these agents may be denied without the required prior authorization and program designation.
- For oncology agents marked ONC and PA, submit PA consistent with oncology program requirements before dispensing.
- Examples: INLYTA, JAKAFI, QINLOCK and multiple others list PA; NM; ONC.
Secure PA for specific drug strengths/formulations marked 'PA'
Obtain prior authorization for individual drug-strength/formulation entries that list 'PA' next to the product; PA must be secured before the prescription is filled when PA is specified.
- Review each drug-strength/formulation line for PA flags and follow PA submission requirements.
- Failure to get PA may result in non‑coverage of the claim.
Submit PA with supporting documentation when PA is flagged
The formulary marks many products with 'PA' but does not include full PA clinical criteria in the drug list; providers must submit PA requests and any supporting clinical documentation as required by the plan.
- When a product is flagged PA, submit supporting documentation consistent with the PA program.
- For biologics and specialty injectables (e.g., ustekinumab/STELARA), include documentation to support medical necessity and dosing.
PA required for select anticonvulsant products (e.g., EPIDIOLEX, FINTEPLA)
Certain seizure and neurology products (for example, EPIDIOLEX, FINTEPLA, NAYZILAM, rufinamide formulations, VALTOCO, VIGABATRIN) are labeled 'PA' on their formulary lines and require prior authorization before coverage.
- Do not dispense these products without an approved PA when the formulary row indicates PA.
- EPIDIOLEX and FINTEPLA are specifically listed with PA; some also show NM.
PA required for selected neurologic/specialty products (e.g., AUSTEDO, KESIMPTA)
Multiple neurologic and movement‑disorder agents (e.g., AUSTEDO formulations, KESIMPTA, NUEDEXTA, tetrabenazine, VUMERITY) are flagged 'PA' on the formulary and require prior authorization for coverage.
- Follow PA and any listed QL or NM requirements for these specialty agents.
- Examples: AUSTEDO/AUSTEDO XR (PA; NM; QL), KESIMPTA pen (PA; NM; QL).
Obtain PA for listed specialty injectables and oral specialty drugs
A range of products across therapeutic areas are labeled 'PA'—prescribers must request prior authorization for those products as indicated in their formulary rows (examples shown include ARISTADA INITIO, armodafinil, AUVELITY, CAPLYTA, COBENFY).
- Confirm PA is obtained before dispensing long‑acting injectables or specialty oral products that list PA.
- Some of these products also carry QL or NM flags that affect coverage.
Get PA for products that list PA in their row (e.g., DRIZALMA, INVEGA HAFYERA)
Certain formulary entries explicitly show PA for listed products (examples: DRIZALMA SPRINKLE, INVEGA HAFYERA, RALDESY); when PA is listed, obtain authorization prior to filling.
- Check the product row for PA and follow PA submission procedures.
- INVEGA HAFYERA is noted with PA on its formulary line.
Submit PA for specific psychotropic and specialty drugs (e.g., TRINTELLIX, VRAYLAR)
The formulary lists many widely used products (e.g., TRINTELLIX, VERSACLOZ, VRAYLAR, ZURZUVAE, UPTRAVI, KERENDIA) with 'PA' noted; providers must submit prior authorization requests for these products when indicated.
- TRINTELLIX — PA; QL (30 per 30 days).
- VRAYLAR and VERSACLOZ show PA (and some also show NM/QL).
PA required for selected biologics (e.g., SKYRIZI, STELARA)
Certain biologic and specialty injectable products are annotated with 'PA' and require prior authorization before coverage (examples include SKYRIZI and STELARA).
- Follow biologic PA processes and supply requested documentation to support medical necessity.
- SKYRIZI and STELARA rows show PA; many biologics also have QL and NM flags.
PA, NM review, and QL apply to DUPIXENT and similar injectables
DUPIXENT and other specialty injectables are marked with PA, NM, and specific quantity limits per 28 days; submit PA requests and documentation and adhere to the stated QL.
- DUPIXENT pen/syringe 200 mg — PA; NM; QL (4.56 per 28 days).
- DUPIXENT 300 mg — PA; NM; QL (8 per 28 days).
Follow PA and Step Therapy flags where shown (e.g., tazarotene = ST)
Some formulary lines carry 'PA' or 'ST' flags (for example BENZEPRO topical towelette is PA; tazarotene topical cream/gel are marked 'ST'); when ST is present, step therapy must be followed before alternative products are covered unless an exception is granted.
- Tazarotene cream/gel: ST; QL (30 per 30 days) — trial requirements apply before coverage.
- BENZEPRO topical towelette is listed with PA.
If step therapy blocks coverage, request exception with prescriber statement
Some drugs are subject to step therapy (designated 'ST'); prescribers may request an exception if the first‑line drug is inappropriate, but an exception requires a prescriber supporting statement.
- If requesting an exception, contact Member Services and provide a prescriber supporting statement.
- Standard exception decisions are made within 72 hours; expedited decisions within 24 hours after the prescriber's statement is received.
Follow product-level 'ST' step therapy designations
Drugs marked 'ST' in the formulary require step therapy per the 'Necessary actions, restrictions, or limits on use' column; review the formulary row for the specific ST designation and follow the listed requirements prior to dispensing.
- Tazarotene topical entries explicitly show 'ST' indicating step therapy applies.
- Check the formulary table under 'Necessary actions...' for product‑specific step requirements.
Follow limited‑access/site‑of‑care notes when 'LA' is shown (e.g., CAYSTON)
Some inhaled products (for example, CAYSTON) are annotated 'LA' in addition to PA, indicating limited access or site‑of‑care considerations; providers should follow any site‑of‑care or limited‑access requirements when seeking authorization.
- CAYSTON shows PA; LA; NM — confirm site‑of‑care rules and obtain PA as required.
- Contact Member Services or consult the pharmacy directory for limited access pharmacy information.
Submit prescriber statement to request an exception via Member Services
To request an exception to PA, QL, or ST rules, the member or prescriber must contact Member Services and provide a prescriber's supporting statement; Member Services will assist in submitting necessary documentation for the exception request.
- Call Member Services to initiate an exception request; a prescriber supporting statement is required.
- Member Services will work with the prescriber; decisions issued within 72 hours (or 24 hours expedited).
Adhere to PA, QL, and NM annotations to avoid denials
Products annotated 'PA' require prior authorization; 'QL' indicates quantity limits and 'NM' indicates the product may be considered not medically necessary in some contexts — these annotations on the formulary can trigger administrative controls and potential denials if not satisfied.
- If a product line shows PA or QL, submit PA or documentation to justify quantities.
- Items marked NM may require additional clinical review and can be denied if criteria are not met.
Submit PA requests with clinical support and dosing documentation for biologics/specialty agents
When PA is required, providers must submit prior authorization requests and supporting clinical documentation consistent with the plan's PA program; for biologics/specialty injectables (e.g., ustekinumab/STELARA) include documentation supporting medical necessity and dosing.
- Submit supporting clinical information with PA requests for biologics and specialty agents.
- Ustekinumab/STELARA entries specify PA; NM; and QL — provide appropriate documentation for approval.
Non‑coverage risk if PA is not obtained
Failure to obtain required prior authorization may result in the plan not covering the drug; claims submitted without an approved PA when PA is required are at risk of denial.
- Before dispensing, verify whether the product row lists 'PA' and secure authorization.
- If PA is not obtained, the plan may deny coverage for the drug.
Background
This Drug List is an administrative formulary for HealthPartners MSHO and describes coverage rules, utilization management codes, and how the plan updates drug coverage. It is the authoritative source for which products are listed and how changes are applied.
Definitions
Step Therapy
| Overview | Source notes |
|---|---|
| Some drugs are subject to step therapy, which requires trying drugs in a specified order before others will be covered; prescribers may request an exception if the first-line drug is inappropriate. | |
| See 'B4' (restrictions: Prior authorization, Quantity limits, Step therapy) and C1 code definitions including ST = Step Therapy Required. |
| ST designation (table flag) | Example entries |
|---|---|
| The formulary uses the 'ST' code to indicate Step Therapy is required for a product. | |
| Tazarotene topical cream and gel entries include 'ST' in the 'Necessary actions, restrictions, or limits on use' column (tazarotene topical cream 0.05% and gel 0.05%/0.1% flagged ST). |
| PA intersection with step therapy | Document note / examples |
|---|---|
| Some agents require prior authorization (PA) before coverage; where PA is indicated the formulary may also apply step therapy but detailed step sequences are not provided in the table excerpts. | |
| Formulary notes explain PA is required for some drugs and that failure to obtain PA may lead to non‑coverage (B4); examples of products with PA include MAVYRET and ARIKAYCE. |
| Oncology / ONC and step | Implication |
|---|---|
| Many antineoplastic and immunosuppressant agents are designated 'ONC' (oncology program) and often carry PA, NM, or QL flags; explicit sequential step‑therapy requirements are not listed in these chunks. | |
| Examples: abiraterone, AUGTYRO, and other antineoplastic agents are marked with ONC and PA/NM/QL as applicable — managed under oncology program processes rather than explicit step sequences in the table. |
| Benefit / medical benefit (B/D) indicators | Example |
|---|---|
| Some oral cytotoxic/immunosuppressive agents are designated B/D (benefit/medical) and may require medical‑benefit processes (B/D PA) before pharmacy coverage is used. | |
| Cyclophosphamide and cyclosporine entries are annotated 'B/D PA; ONC', indicating benefit/medical‑benefit designation with prior authorization and oncology program handling. |
| Migraine / specialty examples | Formulary flags shown |
|---|---|
| Some migraine specialty products list prior authorization (PA) and quantity limits (QL) but do not show a multi‑step therapy algorithm in the excerpt. | |
| Examples: EMGALITY is listed with PA and QL (2 per 30 days for 120 mg pen/syringe; 3 per 30 days for 300 mg syringe); ZTALMY suspension is marked PA; NM; QL. |
| Specialty agents — implied step/criteria | Examples / flags |
|---|---|
| Many specialty agents require prior authorization and are likely subject to clinical criteria or step requirements, though specific step sequences are not shown in the table excerpts. | |
| Examples include KESIMPTA (listed among specialty agents with PA/NM/QL flags), VUMERITY (PA; NM; QL), and AUSTEDO/AUSTEDO XR (PA; NM; QL variations). |
| Specialty injectable antipsychotics / oral specialty drugs | Formulary controls |
|---|---|
| Several specialty injectable antipsychotics and related oral specialty drugs are designated PA and in some cases NM; prior authorization is required before coverage for these agents. | |
| Examples: ARISTADA INITIO and ARISTADA formulations are annotated with PA and/or NM; other specialty psychotropic agents show PA and quantity limits. |
| Higher‑cost branded agents | Utilization controls |
|---|---|
| Many higher‑cost branded agents are subject to prior authorization and may have quantity limits listed before coverage will be approved. | |
| Examples in the formulary include TRINTELLIX (PA; QL 30 per 30 days), VRAYLAR (PA; NM; QL 30 per 30 days), and other branded agents with PA flags. |
| Biologic / antipsoriatic agents | PA / NM / QL |
|---|---|
| Many biologic and specialty antipsoriatic agents require prior authorization (PA) prior to coverage and are often also flagged NM or assigned quantity limits (QL). | |
| Examples: COSENTYX entries show PA; NM; QL (various per 28 days), SKYRIZI and STELARA are listed with PA and QL values; USTEKINUMAB entries include PA; NM; QL (0.5 or 1 per 28 days). |
| Biosimilar example — YESINTEK | Formulary flags / QL |
|---|---|
| YESINTEK (ustekinumab biosimilar) is listed with prior authorization and quantity limits, reflecting parallel utilization controls to the reference product. | |
| YESINTEK entries show 'PA; QL (0.5 per 28 days)' for 45 mg and 'PA; QL (0.5 per 28 days)' for 90 mg syringe strength (parity with reference product controls). |
| Tazarotene topical — step therapy | Table evidence |
|---|---|
| Tazarotene topical cream and gel are explicitly noted with 'ST' in the formulary, indicating a step therapy requirement before coverage. | |
| Formulary rows: tazarotene topical cream 0.05% and tazarotene topical gel 0.05%/0.1% list 'ST' and QL (30 per 30 days) where applicable. |
Quantity Limits (Selected Examples)
Site of Care / Limited Access
Biosimilar Information
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