CurrentHealthPartnersPolicy N/A

Excluded Drug List — Coverage Criteria

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Lists specific drugs and drug formulations that are excluded from coverage under HealthPartners benefits and suggests alternative therapies; intended for providers and members to determine coverage eligibility.

Policy Summary

PayerHealthPartners

PolicyExcluded Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen prescribing, consider suggested alternative drug classes or generic equivalents listed next to excluded branded products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentHealthPartnersPolicy N/A

Excluded Drug List — Coverage Criteria

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Policy Summary

PayerHealthPartners

PolicyExcluded Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen prescribing, consider suggested alternative drug classes or generic equivalents listed next to excluded branded products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Excluded Products and Formulations

This policy maintains an Excluded Drug List that identifies specific branded products and formulations not eligible for coverage under HealthPartners benefits. Examples in this extract include targeted formulations such as BREKIYA 1 mg/ml autoinjector, extended‑release packet products like LUMRYZ ER packets, selected non‑benzodiazepine anxiolytics and hypnotics (for example BUCAPSOL 7.5/10/15 mg capsules and zolpidem tartrate 7.5 mg capsule), and certain combination cardiovascular/NSAID formulations (for example CONSENSI).

The list also designates specific systemic agents and route/formulation variants as excluded, for example: selected NSAID products (TIVORBEX, ZIPSOR, ZORVOLEX), centrally acting muscle relaxants and related products (FEXMID, LORZONE, ZANAFLEX, TONMYA), topical systems and microsphere retinoid formulations (ZTLIDO, RETIN‑A MICRO, tretinoin microsphere products), and other branded dermatology and acne products (DUOBRII, CABTREO).

Additional examples of excluded branded products and formulations shown in this extract include topical and dermatologic agents (RETIN‑A MICRO 0.04%/0.1% gels and tretinoin microsphere formulations), combination topical acne gels (CABTREO 1.2%‑0.15%‑3.15% gel), and a specific acne‑class antibiotic (SEYSARA 60/100/150 mg tablets).

The extract also lists excluded emergency and specialty formulations such as the epinephrine auto‑injector AUVI‑Q (0.15 mg, 0.3 mg) and a liquid sildenafil preparation (LIQREV 10 mg/mL oral suspension), each mapped against the covered therapeutic equivalent (for example, sildenafil tablets for LIQREV).

Provider Actions, Authorization, and Documentation

Denial Risk

Excluded drugs coverage

The Excluded Drug List identifies medications and formulations that are not eligible for coverage under member benefits. Drugs appearing on the Excluded Drug List may result in coverage denial; prior authorization is generally not applicable for excluded products. For benefit questions or to request an exception, contact Member Services at the phone number on the member's ID card.

Excluded drugs are not eligible for coverage under the member's prescription benefit.
Listing on the Excluded Drug List may trigger a denial of payment if billed or dispensed.

Prior Authorization

Prior authorization for excluded formulations

Most excluded formulations do not have a standard prior authorization pathway. Exceptions exist for certain formulations or when coverage exceptions are considered; providers should follow the payer’s exception request process when applicable and include clinical rationale.

Exceptions may be considered for unique clinical circumstances—submit a coverage exception request with full supporting documentation.
Prior authorization is generally not applicable for drugs listed as excluded; check payer exception guidance for specific agents.

Billing Rule

Excluded drug dispensing

Dispensing or billing for drugs listed on the Excluded Drug List risks claim denial and member cost liability. Confirm member benefits before dispensing and document clinical justification when pursuing an exception.

If an excluded drug is dispensed, the claim may be denied and the member may be responsible for payment.
Providers should verify coverage prior to dispensing to avoid unexpected member charges.

Note

Member services contact

When requesting coverage information or to initiate an exception request, contact Member Services at the number on the back of the member’s ID card. Member Services can confirm benefit-specific exclusions and next-step processes.

Use the member ID card phone number for plan-specific benefit confirmation and exception submission guidance.
Document the Member Services contact and advice in the member’s chart when relevant.

Documentation Required

Product equivalence documentation

Requests for coverage exceptions for brand/generic equivalence or therapeutic substitution must include documentation proving product equivalence or clinical rationale for the non-preferred product.

Provide documentation of brand/generic equivalence when the request relies on interchangeability.
Include clinical records demonstrating why therapeutically equivalent preferred agents are inappropriate or ineffective.

Note

Suggested alternatives

When an excluded product has listed alternatives in the source formulary, consider switching to suggested alternatives or preferred therapeutic classes. Suggested alternatives may include generic or formulary-preferred agents (for example: clobetasol, hydrocortisone, triamcinolone as alternatives for certain topical corticosteroid products; diclofenac, ibuprofen, naproxen for some NSAID exclusions; sildenafil for certain PDE-5 product exclusions).

Review the Excluded Drug List's suggested alternatives before submitting an exception request.
Discuss alternatives with the member and document reasons if an alternative is clinically inappropriate.

Step Therapy

Step/therapeutic-equivalent preference

Step therapy or therapeutic-equivalent preference may apply implicitly when an excluded product has preferred alternatives. Providers should document trials and failures of preferred/therapeutically equivalent agents when requesting an exception.

Document prior trials of preferred agents and clinical outcomes when seeking an exception to an excluded drug.
Therapeutic-equivalent agents listed as suggested alternatives are the preferred step before considering coverage of excluded products.

Therapeutic Preferences and Step Therapy Guidance

Preference	Details / examples
Prefer prescribing suggested alternative drug classes or generic equivalents instead of excluded branded products
Examples in the excluded list map branded products to alternative classes or generics (e.g., TIVORBEX, ZIPSOR, ZORVOLEX → diclofenac, etodolac, ibuprofen, naproxen, sulindac; BREKIYA autoinjector → dihydroergotamine ampule). Providers should choose the listed alternatives where clinically appropriate.

Implied within-class preference	Mapped alternative agents / OTC options
Preference for alternative agents within the mapped therapeutic class (use generic or OTC equivalents where listed)
Examples: topical tretinoin cream/gel preferred over RETIN-A MICRO microsphere gel; ZTLIDO topical system mapped to lidocaine 5% or OTC lidocaine 4% patch; skeletal muscle relaxant entries map branded items (FEXMID, ZANAFLEX, LORZONE) to cyclobenzaprine, tizanidine, methocarbamol or chlorzoxazone/metaxalone as appropriate.

Key Definitions and Mappings

Excluded Drug List definition

DefinitionThe Excluded Drug List is a payer-maintained list of select drugs within therapy classes that are not eligible for coverage under the member's benefits.

Coverage implicationDrugs listed on the Excluded Drug List are not eligible for coverage and may be denied when submitted for payment under the member's benefits.

Prior authorization guidancePrior authorization is not applicable to excluded products unless the member's benefits specify an exception or alternate authorization process.

Provider actionProviders should consider the suggested alternative drug classes or generic equivalents listed alongside excluded products when prescribing.

Member supportMembers or providers should call Member Services (number on member ID card) for information on benefits and coverage exceptions.

Policy Background

This payer‑maintained Excluded Drug List is an administrative tool that identifies select branded products, specific formulations, and certain within‑class items that are not eligible for coverage under member benefits. For many entries the list provides a suggested alternative therapeutic class or specific covered agent; providers and members should consult benefits details or contact Member Services for coverage exceptions.

Drugs appearing on the Excluded Drug List may be denied when submitted for coverage unless an exception process applies (for example, when a covered therapeutic equivalent is not appropriate). The list is intended to guide prescribing toward covered alternatives and to document therapeutic equivalents where applicable.