CurrentHealthPartnersPolicy N/A

HealthPartners Formulary — 2025 Drug List (Coverage Criteria)

Defines the HealthPartners drug formulary (covered medicines), tiering, specialty drug handling, and common limits/edits (prior authorization, step therapy, quantity/age limits) for members covered by HealthPartners plans.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Formulary — 2025 Drug List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1st, 2025

Next Review DateN/A

Key ActionObtain prior authorization from HealthPartners when a listed medicine shows a PA requirement prior to coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025Formulary edition year

quarterlyReview frequency

severalProducts with PA

multipleQuantity limits present

requiredSpecialty pharmacy

many

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Opioid program entries

Coverage Determinations & Formulary Placement

Coverage with conditions

Coverage is determined by formulary placement, member plan benefits, and whether specific edits/requirements are met.

Formulary coverage prerequisites: Drug is listed on the HealthPartners drug list AND the member's specific plan includes coverage for that tier/benefit

Member should verify tier-specific cost sharing via Summary of Plan Benefits or myHealthPartners account

Authorization edits: For drugs flagged with PA, ST, AL1, AQ1, or QL, the corresponding requirement must be satisfied (e.g., prior authorization approved; required step therapy trial completed; patient meets age limits; requested quantity is within the listed quantity limit)

Specific clinical criteria and documentation requirements for each PA/ST are maintained by HealthPartners

Specialty medicines: When product is designated Specialty or S, it must be dispensed via an authorized specialty pharmacy and may be covered under a different medical/pharmacy benefit; any specialty program requirements and prior authorization rules must be met

Members and ordering providers should check the Medical Plan tab or secure account for specialty benefit details

A Non-Preferred Drug (NP) is included on the HealthPartners formulary but is designated to carry a higher member cost share compared with preferred alternatives. Non-preferred status is not a coverage exclusion — the product remains on the drug list — but members should expect increased out-of-pocket costs unless a plan-specific exception or prior authorization applies. Providers and members should check the member’s secure account or benefit summary to confirm the exact copay/coinsurance for an NP product.

Formulary entries may display the label "NP" or extended phrases such as "Non-Preferred Drug" (examples include branded long-acting injectables and certain antipsychotic products). The NP designation is shown in the Limits & Restrictions field alongside other program flags (e.g., PA, ALI, OP) and signals a formulary preference hierarchy that can affect cost sharing and utilization management for that product.

Some products combine NP with other restriction markers (for example, PA or age limits). Where entries show NP together with prior authorization or program codes, coverage may require both prior approval and acceptance of the higher cost share associated with non-preferred placement.

This formulary segment does not define specific medical necessity criteria for individual products; instead it lists products with their tier, Limits & Restrictions flags (e.g., PA, QL, NP, age limits) and per-product utilization notes. Coverage decisions are governed by whether the drug is on the drug list, the member’s plan benefit for that tier, and whether any listed edits (prior authorization, quantity or age limits, trial/drug programs) are satisfied.

Because the document provides product/tier listings and utilization annotations rather than clinical criteria text, providers seeking coverage rationale or to initiate prior authorization should reference the specific Limits & Restrictions codes on the formulary entry and follow HealthPartners’ authorization procedures or the member’s benefit details.

Codes, Flags, and Quantity Examples

Formulary product-specific quantity/limits as printedmixed

29 TABS 90 DAYS	JOURNAVX limits & restrictions (as listed)
20 TABS 30 DAYS	ERGOMAR limits & restrictions
60 ML / 1 DAY	acetaminophen with codeine solution quantity limit
40 TABS 30 DAYS	ergotamine tartratelcaffeine limits & restrictions

Formulary restriction codes (observed)mixed

PA	Prior Authorization required (as listed in Limits & Restrictions)
QL	Quantity Limit
ALI	Age Limit Indicator (e.g., 'At least 12 yrs old')
OP	Opioid Program

Program or indication codesmixed

WL	Weight Loss program / restriction
NP	Non-Preferred (NP) referenced alongside QL/PA in entries

No explicit CPT/HCPCS/ICD-10/NDC codes in this excerptmixed

No codes listed

Formulary entries with limits (no billing codes present)mixed

No codes listed

Therapeutic class headings (no CPT/HCPCS/ICD codes in this section)mixed

No codes listed

Formulary flags / limits codes presentmixed

PA	Prior Authorization / program flag
QL	Quantity Limit
TD	Trial Drug
ONC	Oncology designation
OH	OncoHealth program designation
S	Specialty Drug
NP	Non-Preferred Drug

Products explicitly named in this fragmentNDC|drug_name

mercaptopurine 50 mg tablet	listed product
melphalan	listed product
methotrexate sodium/pf 25 mg/ml vial	listed product
MYLERAN	listed product
NEXAVAR	listed product

inv-13: Quantity limits examples (per period)

Example: ERGOMAR20 TABS / 30 DAYS

Example: JOURNAVX29 TABS / 90 DAYS

General noteFormulary entries list per-period limits (use Tier to verify member cost sharing)

inv-14: Examples of quantity limits

Example: per-day tablets8 TABS / DAY (acetaminophen with codeine 300 mg formulations)

Authorization, Documentation, and Step Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for many medicines listed with PA, PA NP, PA S, PA.ONC, PA TD or similar flags in Limits & Restrictions. Even if a product appears on the drug list, coverage under pharmacy benefits may be denied or limited unless prior authorization criteria are met.

PA flags include: PA, PA NP (prior auth + non‑preferred), PA S (prior auth + specialty), PA.ONC (prior auth routed to oncology program), PA TD (prior authorization with Trial Drug flag)
Many specialty and oncology agents are routed through program flags (ONC, OH, S, Trial Drug) and also require PA — submit via the program specified
Examples of products commonly requiring PA: opioid extended‑release/partial agonists (e.g., buprenorphine, hydromorphone ER, oxycontin), select anti‑infectives (albendazole, flucytosine, voriconazole), selected anticonvulsants (vigabatrin, rufinamide, DIACOMIT), weight‑loss/incretin agents (liraglutide, Mounjaro, Wegovy, Zepbound)
Some agents carry combined requirements: PA plus specialty dispensing (S) — examples include many clotting factors (ALTUVIIIO, BENEFIX), specialty antivirals or oncology agents (INLYTA, JAKAFI)

Step Therapy & Trial Drug Indicators

Requirement	Action for provider
Step therapy completion or verification
If step therapy (ST) applies, member must have tried the required alternative(s) first; if not, provider must obtain approval from HealthPartners for coverage at the preferred copay/coinsurance

Product	Formulary flags / implications
NUCYNTA (tapentadol) 50 mg, 75 mg tablets
Listed with QL, PA and Non-Preferred (NP) annotations (e.g., 'QL PA NP' / 'Non-Preferred Drug Opioid Program') — may require prior authorization and indicates non-preferred status that could imply step requirements or higher member cost share

Category / examples	Formulary flag and implied authorization pathway
Anorexigenics; Respiratory/CNS stimulants (e.g., lisdexamfetamine, amphetamines, CONTRAVE, phentermine/topiramate)
Entries include 'WL' / 'Weight Loss' and QL or PA flags — indicates program-specific weight-loss authorization pathways and potential step requirements though explicit sequences are not provided

Observation	Implication
Multiple products listed with Non-Preferred (NP) and/or Prior Authorization (PA) designations
NP and PA labels suggest utilization management and may imply preferred-agent step requirements, but explicit step therapy sequences are not provided in the excerpt

Example product	Limits & Restrictions
BAXDELA 450 mg tablet
Listed as 'PA NP' and noted as Non-Preferred Drug — PA/NP flags indicate prior authorization and non-preferred status which may be managed via step or other utilization controls

Example product / formulation	Formulary annotation and implied step preference
FYCOMPA 0.5 mg/mL oral suspension
Marked with QL and PA NP in listings elsewhere; Non-Preferred (NP) annotation suggests preferred-agent step requirements could apply though explicit steps are not shown

Product	Step therapy flag
TRINTELLIX (vortioxetine)
Entry includes an 'ST' (step therapy) flag indicating step therapy applies

Observation	Notes
Multiple branded products show NP or PA annotations (examples: EMSAM marked PA/NP; diverse class entries show NP)
NP/PA designations imply utilization controls and possible step/management requirements, but the excerpt does not provide explicit step therapy rules or sequences

Flag	Meaning for coverage
Trial Drug (example: OPIPZA, risperidone, quetiapine entries)
'Trial Drug' annotation indicates a required trial (often with age/ALI qualifiers like 'At least 7 yrs old') of another therapy prior to coverage of the listed product

Per-Product Quantity and Day-Supply Limits

inv-112: ERGOMAR — 20 TABS (and related examples)

EROGMAR (ERGOMAR)20 TABS (listed as 20 TABS / 30 DAYS)

JOURNAVX29 TABS (listed as 29 TABS / 90 DAYS)

Acetaminophen with codeine solution60 ML / 1 DAY (per‑day liquid limit)

inv-113: JOURNAVX — 29 TABS

JOURNAVX29 TABS (listed in formulary limits)

ContextAppears alongside other migraine/ergot product limits in Oncology/therapeutic listings

Specialty Pharmacy & Care Setting Requirements

Note

Key Definitions & Abbreviations

inv-90 / inv-91 / inv-187: Tier, abbreviations, specialty pharmacy (definitions)

Tier (T1/T2/T3)Tier indicates member cost‑sharing level for a medicine (e.g., T1 = Formulary Low Cost Generics).

AbbreviationsPA = Prior Authorization; ST = Step Therapy; AL1 = Age Limit; AQ1 = Age Quantity Limit; QL = Quantity Limit; NP = Non‑Preferred Drug

Specialty pharmacySpecialty medicines must be filled at a specialty pharmacy and may be covered under a different benefit

Formulary Scope & Purpose

The formulary is organized by therapeutic class and tier to guide coverage and member cost sharing: tiers indicate relative cost-share levels (for example, lower-cost generics vs. formulary brands). Specialty medicines are high-cost products for complex or chronic conditions and frequently require additional management; many specialty agents are dispensed via a specialty pharmacy and may be covered under a different benefit.

Specialty designation commonly triggers extra utilization controls such as program routing (e.g., Oncology/OncoHealth), prior authorization, or specialty dispensing requirements. Providers should verify the site-of-care rules and whether a requested specialty medicine must be filled through the designated specialty pharmacy or routed to an oncology program when applicable.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Formulary — 2025 Drug List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1st, 2025

Next Review DateN/A

Key ActionObtain prior authorization from HealthPartners when a listed medicine shows a PA requirement prior to coverage.

SourceLink

On This Page

Example: liquid solution60 ML / 1 DAY (acetaminophen with codeine solution)

Example: small-count tablet limit5 TABS / DAY (oxycodone combination examples)

inv-15: Per-day quantity limits

1 CAP / 1 DAYObserved for some higher‑strength stimulant and methylphenidate ER products

2 CAPS / 1 DAYCommon limit for many methylphenidate ER strengths and atomoxetine formulations

3 TABS / DAYListed for some tramadol ER and methylphenidate formulations

inv-16: Example quantity limits

1 CAP / 1 DAYExample limit used across stimulant/ADHD formulations

30 ML / DAYMethylphenidate oral solution example (10 mg/5 mL variants)

44 GM / 1 FILLTopical mupirocin quantity limit per fill

inv-17: Examples of quantity thresholds

44 GM / 1 FILLMupirocin topical limit per fill

15 GM / 1 FILLAcyclovir 5% ointment per‑fill limit

100 GM / 30 DAYSPimecrolimus / tacrolimus topical examples (100 GM per 30 days)

inv-18: Examples of quantity/day limits

2 PENS / 28 DAYSADBRY autoinjector limit (2 pens per 28 days) and similar pen limits for biologics

1 SYRINGE / 84 DAYSSKYRIZI 150 mg/mL syringe limit (1 syringe / 84 days)

1 SYRINGE / 84 DAYS (example) - VRAYLAR dosing notePer‑day and per‑pack limits vary by strength (see VRAYLAR examples: 2 caps/day for 1.5 mg; 1 cap/day for 3/4.5 mg)

inv-19 (alternate): Sample quantity limits

8 TABS DAYShown for several products (e.g., tramadol HCl 50 mg) in the formulary extract

2 TABS DAYCommonly used class‑level limit (sulfonylureas, others)

51 TABS / 30 DAYSXARELTO DVT‑PE TREAT START 30D example (51 tabs / 30 days)

inv-20: Quantity limits examples (GLP‑1s & others)

Lacosamide solution40 mL / DAY (lacosamide 10 mg/mL solution)

Liraglutide (0.6 mg pen)3 pens (9 mL) per 30 days

Mounjaro (tirzepatide)4 pens (2 mL) per 28 days

inv-20 (duplicate mapping): Examples of quantity limits (alternate)

3 TABS / DAYTramadol ER 100 mg tablet listed with 3 tabs/day

21 CAPS / 28 DAYSExample oncology/antineoplastic capsule‑per‑period limit (lenalidomide listed elsewhere)

42 TABS / 28 DAYSKISQALI 200 mg example; multiple tab/28‑day oncology limits shown

inv-22 (duplicate mapping): Example quantity limits

4 CAPS / 1 DAYExample oncology/cancer therapy capsule limit appearing in product descriptions

21 CAPS / 28 DAYSPazopanib HCl example limit (21 caps/28 days)

PACKET / 1 DAYROZLYTREK 50 mg pellet packet = 1 PACKET / 1 DAY

inv-23 (alternate): Quantity limits examples

8 TABS / DAYTramadol HCl 50 mg tablet example limit (8 tabs/day)

2 TABS / DAYCommon wakefulness‑promoting/antagonist examples (modafinil/armodafinil)

1 CAP / 1 DAYHigher‑strength methylphenidate ER cap examples (1 cap/day)

inv-24: Per-day quantity limit example (VRAYLAR and biologics)

VRAYLAR dosing exampleVRAYLAR 1.5 mg pack = 2 CAPS / 1 DAY; VRAYLAR 3 mg/4.5 mg = 1 CAP / 1 DAY

AJOVY1.5 mL per 28 days (autoinjector) as a per‑period example

EMGALITY3 mL per 28 days (varies by presentation) — listed as QL PA

Documentation Required

Quantity Limits and Documentation

Quantity limits (QL) are actively enforced. Requests that exceed listed QL or per‑day caps will be reviewed for medical necessity and may be denied without adequate supporting documentation.

When requesting PA for a quantity above the QL, include diagnosis, prior therapies tried, prior use of the product at requested quantity, and evidence of efficacy/safety at the requested dose
Common QL examples: topical mupirocin (44 g / fill), migraine biologics and CGRP agents (AJOVY, EMGALITY: 1.5 mL / 28 days; NURTEC: 8 tabs / 30 days), biologic syringes/pens (SKYRIZI: 1 syringe / 84 days)
Over‑the‑counter or topical agents may also have grams/ml per fill limits that must be documented

Step Therapy

Non‑Preferred, Step Therapy, and Trial Requirements

Non‑preferred (NP) status and combined NP + PA flags increase denial risk if PA is not obtained. Step therapy (ST) or Trial Drug (TD) flags can require trials of preferred agents before coverage of the requested product.

If Limits & Restrictions lists NP or PA NP, obtain PA before dispensing to avoid denial
Step Therapy (ST) requires documented trials of specified alternatives; Trial Drug (TD) indicates required trial program routing
Weight‑loss (WL) program flags (e.g., Wegovy, Zepbound, CONTRAVE) and other program flags require enrollment or PA per program rules

Prior Authorization

Program Flags and Oncology Routing

Certain therapeutic areas have specialized routing and program flags. Oncology and OncoHealth (ONC, OH) products frequently require PA routed to the oncology program and may carry additional Trial Drug or Specialty identifiers.

Oncology products may show PA.ONC or PA with ONC/OH flags — follow program routing (OncoHealth or Specialty) when submitting authorizations
Examples: ROZLYTREK (PA, ONC), INLYTA (PA.ONC), many oral antineoplastics show QL.PA.ONC or PA.ONC
Provide oncology‑specific documentation per program guidance (diagnosis, line of therapy, prior regimens, genomic test results when applicable)

Documentation Required

Age and Program Enrollment Verification

Age limits, opioid program enrollment, and specialty program enrollment must be verified when present. Include age and program enrollment documentation with PA requests.

Age limits (ALI/AL1) — confirm patient meets minimum age listed (examples: many opioid agents: At least 12 yrs old; XARELTO suspension: at least 18 yrs)
Opioid Program (OP / Opioid Program) — products flagged for the Opioid Program require program compliance and may have daily caps
Specialty (S) flags — specialty drugs (S) generally require prior authorization and specialty pharmacy dispensing

Documentation Required

Authorization Submission Expectations

When submitting authorizations include: diagnosis, prior medications/trials, quantity and day‑supply justification, prior use of the requested product, and any program or specialty enrollment information. For oncology or trial‑drug products, include treatment history and relevant testing.

Documentation checklist: diagnosis and indication, prior therapies with dates/doses, reason alternatives not appropriate, requested quantity/day supply and clinical rationale, age verification and program enrollment as applicable
For products with QL + PA flags (e.g., liraglutide, Mounjaro, rufinamide), explain why requested quantity exceeds standard limits
If product is NP or PA NP, note formulary tier and justify medical necessity for non‑preferred selection

inv-114: acetaminophen with codeine solution — 60 ML

acetaminophen with codeine solution60 ML (per day liquid limit)

Age noteOften listed with Age Limit (At least 12 yrs old) and Opioid Program flags

inv-115: ergotamine tartrate/caffeine — 40 TABS

ergotamine tartrate/caffeine40 TABS / 30 DAYS

Formulary contextListed under migraine/ergot products with QL flag

inv-116: acetaminophen with codeine 300mg formulations — 8 TABS

acetaminophen with codeine 300 mg formulations8 TABS / DAY

Age/program flagsEntries often include Age Limit and Opioid Program annotations

inv-117: acetaminophen with codeine solution — 60 ML (repeat)

acetaminophen with codeine solution60 ML / DAY (duplicate listing across entries)

NoteListed with QL and opioid program flags in multiple rows

inv-118: morphine sulfate 15 mg tablet — 5 TABS

morphine sulfate 15 mg tablet5 TABS / DAY

Other morphine formulationsVarious morphine solutions show ML/day limits (e.g., 20 ML/day for 20 mg/5 mL)

inv-119: oxycodone 5 mg/5 ml solution — 40 ML

oxycodone 5 mg/5 ml solution40 ML / DAY

ContextListed under Opioid Program and QL restrictions

inv-120: tramadol ER 100 mg tablet — 3 TABS

tramadol ER 100 mg tablet3 TABS / DAY

Formulary noteListed with QL and sometimes PA or age limits

inv-121: tramadol ER and IR products — varies by product

tramadol ER and IR productsLimits vary by product (examples: 3 TABS/DAY up to 8 TABS/DAY depending on formulation)

Age/opioid programFrequently accompanied by Age Limit and Opioid Program flags

inv-122: buprenorphine products — examples

Buprenorphine products (examples)12 TABS / DAY (2 mg); 3 TABS / DAY (8 mg); 3 FILMS / 1 DAY; 2 FILMS / DAY (12/3 mg film)

NotesShown with QL, PA, ALI and Opioid Program annotations

inv-123: lisdexamfetamine formulations — daily limits vary

Lisdexamfetamine formulations1–2 caps/tabs per day depending on strength (e.g., 1 CAP / 1 DAY for higher strengths; 2 TABS / DAY for chewables)

Formulary flagListed with QL and weight‑loss (WL) program indicators for some formulations

inv-124: atomoxetine; dexmethylphenidate; METADATE ER examples

Atomoxetine / Dexmethylphenidate / METADATE ER examplesLimits include 1 CAP / 1 DAY or 2 CAPS / 1 DAY or 2 TABS / DAY depending on product/strength

METADATE ER3 TABS / DAY for specific ER caps

inv-125: methylphenidate/dexmethylphenidate/atomoxetine examples

Methylphenidate / Dexmethylphenidate / AtomoxetineExamples across strengths: 1 CAP / 1 DAY; 2 CAPS / 1 DAY; 2 TABS / DAY; 3 TABS / DAY; 4 TABS / DAY — varies by formulation

Provider noteCheck specific strength entry for exact per‑day cap

inv-126: methylphenidate solution — 30 ML / DAY or 60 ML / DAY

Methylphenidate solution30 ML / DAY or 60 ML / DAY depending on strength (e.g., 10 mg/5 mL variants)

Formulary contextSolution limits specified as mL/day in product rows

inv-127: mupirocin — 44 GM / 1 FILL

Mupirocin44 GM / 1 FILL

Formulary tierListed under Formulary Low Cost Generics with QL

inv-128: fosfomycin tromethamine — 3 PACKETS RX

Fosfomycin tromethamine3 PACKETS / RX

NoteListed with QL PA NP in some entries

inv-129: mupirocin — 44 GM (duplicate)

Mupirocin (repeat)44 GM (per fill) — topical QL

DocumentationQuantity limit should be documented on prescription/claim

inv-130: acyclovir 5% oint — 15 GM

Acyclovir 5% ointment15 GM / 1 FILL

Formulary noteListed under antivirals (skin) with QL per fill

inv-131: pimecrolimus — 100 GM; tacrolimus — 100 GM

Pimecrolimus100 GM (per 30 days)

Tacrolimus 0.1% oint100 GM (per 30 days)

inv-132: SKYRIZI syringe/on‑body limits

SKYRIZI 150 mg/mL syringe1 SYRINGE / 84 DAYS

SKYRIZI on‑body cartridge1 CARTRIDGE / 56 DAYS

inv-133: SKYRIZI 150 MG/ML SYRINGE — 1 SYRINGE

SKYRIZI 150 MG/ML SYRINGE1 SYRINGE

Per periodListed as 1 syringe per 84 days in product rows

inv-134: ADBRY AUTOINJECTOR — 2 PENS

ADBRY autoinjector2 PENS / 28 DAYS

Formulary contextListed with QL limits for biologic autoinjectors

inv-139: linezolid 600 mg tablet — 2 TABS

Linezolid 600 mg tablet2 TABS (per product listing)

Formulary noteListed under PHOSPHODIESTERASE‑4 / antibiotics with QL

inv-140: rivaroxaban suspension; XARELTO tablet limits

Rivaroxaban 1 mg/mL suspension (reconstructed)20 ML / DAY

XARELTO tabletsTAB / DAY (per‑day tablet dosing) and XARELTO DVT‑PE TREAT START = 51 TABS / 30 DAYS

inv-141: XARELTO (DVT-PE start) — 51 TABS

XARELTO DVT‑PE TREAT START 30D51 TABS / 30 DAYS

General XARELTOTab / Day limits noted for maintenance dosing

inv-138: SKYRIZI ON-BODY — 1 CARTRIDGE

SKYRIZI ON‑BODY1 CARTRIDGE / 56 DAYS

Use noteOn‑body cartridges treated as specialty drug with per‑cartridge limits

inv-143: FYCOMPA 0.5 mg/mL oral suspension — 8 ML

FYCOMPA 0.5 mg/mL oral suspension8 ML / 1 DAY

Formulary flagListed with PA and NP annotations in product row

inv-144: clobazam suspension; gabapentin solution examples

Clobazam 2.5 mg/mL oral suspension16 ML (per product listing)

Gabapentin solution variantsExamples include 72 ML limits per listing

inv-145: gabapentin/pregabalin quantity examples

Gabapentin solution variants72 ML (example limit) — product rows list packet/day or ML/day limits

Pregabalin 150 mg capsule4 CAPS (per day)

Pregabalin 200 mg capsule3 CAPS (per day)

inv-148: lacosamide 10 mg/mL solution — 40 mL/day

Lacosamide 10 mg/mL solution40 mL / DAY

TabletsLacosamide tablets listed with 2 TABS / DAY for some strengths

inv-149: liraglutide and Mounjaro pen limits

Liraglutide 0.6 mg pen3 PENS (9 mL) / 30 DAYS

Liraglutide 3 mg pen5 PENS (15 mL) / 30 DAYS

Mounjaro (tirzepatide)4 PENS (2 mL) / 28 DAYS

inv-152: Ozempic/Wegovy/Zepbound — pen limits

Ozempic penPEN (3 mL) — 28 days per pen (3 mL)

Wegovy4 PENS (2 mL) or 4 PENS (3 mL) per 28 DAYS depending on strength (weight‑loss formulations)

Zepbound4 PENS (2 mL) per 28 DAYS

inv-155: Ozempic pen — 28 days per pen; Trulicity example

Ozempic (3 mL pen)28 days per pen (3 mL)

Trulicity4 pens (2 mL) per 28 days

inv-158: Sulfonylureas class-level — 2 tabs/day

Sulfonylureas (class‑level)2 TABS / DAY (class notation) — typical per‑day class limit

ApplicabilityApplies across many sulfonylurea entries in the formulary

inv-159: Ciclopirox / Nystatin quantity examples

Ciclopirox suspension60 ML / 30 DAYS (suspension example)

Nystatin powder240 GM / RX (nystatin 100000/g powder)

Nystatin oral suspension480 ML / RX (100000 U/mL oral suspension)

inv-160: nystatin 100000/g powder — 240 GM

Nystatin 100000/g powder240 GM per prescription

Nystatin oral suspension 100000 U/mL480 ML per RX

inv-162: tranexamic acid 650 mg tablet — 30

Tranexamic acid 650 mg tablet30 TABS (per prescription)

Formulary tierListed under Formulary High Cost Generics with QL

inv-163: AJOVY / EMGALITY / NURTEC quantity examples

AJOVY autoinjector1.5 mL per 28 days

EMGALITY 120 mg/mL syringeListed with ML per 28 days (product‑specific)

NURTEC ODT8 TABS / 30 DAYS

inv-164: AJOVY / EMGALITY / REYVOW examples

AJOVY autoinjector1.5 mL (per 28 days)

EMGALITY (pen/syringe)3 mL per 28 days (varies by presentation)

REYVOW8 TABS / 30 DAYS

inv-170: sumatriptan — varies by formulation

Sumatriptan formulationsVaries by formulation: 12 tabs / 28 days (tablets), 12 sprays / 30 days (spray), 5 mL / 30 days (injectable) — per listing

DocumentationPrescriptions should match the listed formulation limit

inv-171: lenalidomide — 21 CAPS

Lenalidomide (various strengths)21 CAPS / 28 DAYS

Oncology flagListed with OncoHealth/PA/QL program tags

inv-172/173/174: KISQALI daily dose examples

KISQALI 200 mg daily dose42 TABS / 28 DAYS

KISQALI 400 mg daily dose63 TABS / 28 DAYS

KISQALI 600 mg daily dose49 TABS / 28 DAYS

inv-175/176: everolimus & lapatinib dosing examples

Everolimus (some strengths)3 TABS / DAY (example per listing)

Lapatinib ditosylate1 CAP / 1 DAY

inv-177/178/179: pazopanib & ROZLYTREK examples

Pazopanib HCl21 CAPS / 28 DAYS

ROZLYTREK 100 mg capsule3 CAPS / 1 DAY

ROZLYTREK 50 mg packet1 PACKET / 1 DAY

inv-180/181/183: general examples including VANFLYTA and XTANDI

8 TABS / DAY (general)Seen in oncology and other product listings as an example daily cap

VANFLYTA2 TABS / DAY

XTANDI 40 mg4 CAPS / 1 DAY

inv-184/185: ZEJULA and VRAYLAR examples

ZEJULA1 CAP / 1 DAY (for some strengths)

VRAYLAR (1.5 mg pack)2 CAPS / 1 DAY — VRAYLAR per‑strength dosing examples