CurrentHealthPartnersPolicy N/A

HealthPartners Formulary (2026 Drug List) — Coverage & Utilization Controls

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This document is the HealthPartners 2026 formulary drug list and explanatory guide describing how medicines are categorized, coverage rules (e.g., prior authorization, step therapy, quantity limits), and benefit details for members and providers.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Formulary (2026 Drug List) — Coverage & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization when a product is flagged 'PA' and submit required documentation per the formulary table.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026Formulary year

QuarterlyReview frequency

PA, ST, AL, QLCommon limits

TD: first 6 fillsTrial Drug Program

OTC not coveredOTC coverage stance

Formulary Coverage & Requirement Flags

Formulary coverage with utilization management markers

Coverage is indicated by drug presence on the formulary with utilization management markers; specific medical-necessity decision trees are not included in this extract.

Formulary presence: Drugs listed with a Drug Tier value are covered on the formulary subject to the Requirements Limits codes shown (PA, NP, QL, S, ONC, TD, ACA).

Full clinical coverage criteria and indications are in other sections not included here

Coverage controls by requirement flags

Coverage and utilization controls apply as indicated by requirement flags next to each product line.

Specialty/coagulation products: Products listed with 'PA; S' require prior authorization and specialty management; coverage is contingent on approval and any specialty program enrollment.

Examples include intravenous coagulation factor products (ADVATE, ADYNOVATE, ALPHANATE, ALPHANINE, ELOCTATE) shown with PA; S.

Products with ENH/QL: Some agents have enhanced edits (ENH) and quantity limits (QL) that govern allowable dispensing quantities and may require additional documentation or program criteria.Specific QL values are provided per product in the table (e.g., QL (2 per 1 day), QL (6 per 1 day)).

Noncompliant claims may require override or be denied.

Preventive/Preferred flags: Products labeled PREV or ACA indicate preventive/preferred designations or ACA-mandated coverage that affect benefit handling; refer to the formulary header for symbol definitions.

Exact coverage implications are defined at the table header (not included in these chunks).

Formulary coverage indications

Coverage is indicated by formulary inclusion with an assigned Drug Tier and 'Requirements Limits' label (for example, ACA); some agents also show OTC status and quantity limits.

Formulary inclusion: Drug appears on the formulary with a specified Drug Tier and Requirements Limits label (commonly 'ACA' for contraceptives/vaccines in this segment).

See the full table header for definitions of requirement/limit labels and ACA/OTC implications.

Over-the-counter (OTC) drugs are generally not covered unless otherwise noted. The formulary identifies OTC items (for example, low‑dose aspirin 81 mg) with ACA/OTC designations; where an OTC product is specifically listed with coverage designations in the drug table, follow the table entry. Providers and members should verify member-specific benefits for OTC coverage via the member's plan details.

Weight‑loss medications are managed separately and may not be covered under all plans. Several agents in the Weight Loss (WL) category are flagged with utilization controls such as PA (prior authorization) and QL (quantity limits) and some are identified with WL program requirements; coverage depends on the member’s specific benefit. Providers should check the member’s plan benefits in myHealthPartners to confirm whether a weight‑loss medicine is a covered benefit and whether prior authorization or quantity limits apply.

Infertility medicines may not be covered under all plans and frequently have program‑specific limits or specialty handling. The formulary indicates infertility and fertility‑related products with flags (for example S or INF) and some products may require specialty routing; providers must verify member benefits via myHealthPartners to determine coverage and prior authorization requirements.

Within this extracted segment there are no explicit categorical exclusion conditions listed. The pages provided are predominantly formulary listings with tier and requirement symbols; formal exclusion rules (if any) are defined elsewhere in the full formulary document.

This segment does not contain standalone medical‑necessity decision criteria or explicit exclusion statements. Coverage indications in these chunks are administrative — drugs are shown with Drug Tier assignments and requirement flags (e.g., PA, QL, S); clinical medical‑necessity rules are found in other sections not included here.

Exclusions are not enumerated within this extract. The content here is a formulary listing showing product lines, tiers, and requirement labels (for example ACA for certain preventive vaccines); explicit exclusions, if present, are specified elsewhere in the full formulary.

Programmatic markers such as NP (new product/program restriction) and S (specialty) appear in the table and reflect utilization controls or routing rather than explicit exclusions. While these flags may limit where or how a product is dispensed, this fragment does not list discrete excluded product lists or exclusion criteria.

The material in these chunks is primarily a formulary listing of drug product lines with tier assignments and requirement/limit codes. It is not presented as a standalone coverage‑criteria statement; coverage is shown by formulary inclusion and the associated requirement flags (e.g., PA, QL, S), with clinical criteria located elsewhere in the full policy.

No specific additional coverage criteria or exclusions are explicitly listed in these chunks. The entries mainly indicate contraceptive products with ACA designation and associated quantity limits. For full coverage rules consult the complete formulary and the table header definitions.

This extracted fragment does not include any 'not medically necessary' language. Where the formulary applies utilization controls (PA, QL, ST, NP), claims exceeding those controls will be reviewed for medical necessity, but no explicit NMN statements are present in these chunks.

No explicit 'not medically necessary' determinations are contained within this segment. The listings show product tiers and requirement labels (for example ACA for vaccines) but do not declare specific services or products to be not medically necessary in this extract.

Across these chunks there is no explicit 'not medically necessary' language. The document portion provided is a formulary drug list with utilization flags and quantity limits; determinations of medical necessity would be applied per standard prior authorization and coverage review processes when applicable.

Codes, Abbreviations & Program Limits

Formulary Drug Codes (sample entries)NDC

ciprofloxacin_oral_tablet_250_mg	ciprofloxacin oral tablet 250 mg
ciprofloxacin_oral_tablet_500_mg	ciprofloxacin oral tablet 500 mg
ciprofloxacin_oral_tablet_750_mg	ciprofloxacin oral tablet 750 mg
valganciclovir_oral_tablet_450_mg	valganciclovir oral tablet 450 mg
viread_oral_tablet_200_mg	VIREAD oral tablet 200 mg
cefadroxil_oral_tablet_1_g	cefadroxil oral tablet 1 gram

Requirement/Limit codes used in tablemixed

PA	Prior Authorization
NP	Network Pharmacy / Not Preferred
QL	Quantity Limit (examples: QL (4 per 30 days), QL (180 per 30 days), QL (2 per day), QL (6 per 30 days))
S	Specialty
ONC	Oncology
TD	Trial Drug Program (first fills may be limited)
ENH	Enhanced benefit / special packaging
ACA	ACA preventive benefit
PREV	Preventive

Trial Drug Program initial fills — first 6 fills may be limited to less than a month supply

Trial Drug Program (TD)First 6 fills of a trial drug may be limited to less than a month supply; if medicine works, remainder of month supplied; copay limited to one copay per one-month supply.

Opioid initial supply — new opioid prescriptions limited to smaller supply

Opioid Program (OP)New opioid prescriptions are limited to a smaller supply for the first prescription; longer therapy requires prior authorization.

Quantity limits — examples include QL (4 per 30 days), QL (180 per 30 days), QL (2 per day), QL (6 per 30 days)

Quantity limits examplesExamples include QL (4 per 30 days); QL (180 per 30 days); QL (2 per day); QL (6 per 30 days)

Sample quantity limits — examples include 0.75/day; 1/day; 8/day; 4/day; 2/day; QL per 30 days

Sample quantity limitsExamples shown in formulary: 0.75/day; 1/day; 8/day; 4/day; 2/day; QL per 30 days

Quantity Limits examples — e.g., QL (2 per 1 day), QL (0.8 per 1 day), QL (6 per 1 day)

Quantity Limits examplesAdditional examples: QL (2 per 1 day), QL (0.8 per 1 day), QL (6 per 1 day)

Prior Authorization, Step Therapy & Documentation

Prior Authorization

Prior Authorization Required

Many drugs on this list require prior authorization (PA) before they will be covered under a member's pharmacy benefit. Even when a medicine appears on the drug list, coverage may be denied without an approved PA. Providers must obtain PA for any product marked "PA" or otherwise flagged with prior-authorization requirements in the table prior to dispensing.

PA = Prior Authorization — claims for PA‑flagged products may be denied without prior approval.
PA-coded products include numerous specialty, oncology, biologic, coagulation and high‑cost injectable agents (examples in the table: many oncology agents, coagulation factor products, specialty biologics).
Opioid Program (OP) — longer opioid therapy and many extended‑release opioid formulations require PA; initial opioid prescriptions may be limited in supply.
ACA & ACA‑PA — some Affordable Care Act preventive medications are covered but certain ACA‑designated products may still require PA (ACA‑PA).
Weight‑loss and infertility medicines — coverage and limits vary by plan; many weight‑loss drugs in the list carry WL and PA flags and may be excluded depending on member plan.

Documentation Required

Quantity Limits, Documentation & Denial Risk

Quantity limits (QL), specialty/site indicators (S, INF), oncology (ONC) and program flags (ENH, PREV, OP, GH, INF, WL) in the drug table affect coverage and documentation expectations. Requests above specified QL will be reviewed for medical necessity and require documentation (diagnosis, prior therapies tried, evidence of efficacy/safety). Exceeding QL or dispensing without required PA may result in denial or reduced reimbursement.

QL = Quantity Limit — many products have per‑day or per‑period QL entries (examples: biologics and injectables with per‑day QL values).
Requests above QL will be reviewed and must include supporting documentation (diagnosis, alternatives tried, prior use within QL, clinical rationale, evidence of benefit).
For products marked S (Specialty) or INF (infusion/administration) additional pharmacy/site requirements and documentation may apply.
Some oral anticoagulants and other chronic therapies have ENH (enhanced) edits and QL that affect claims processing.

Step Therapy

Step Therapy & Program Flags

Step therapy (ST) applies where indicated: providers must document trials of required alternatives before coverage at the preferred cost share. Program or enhanced review flags (ENH, TD, PREV) and specialty enrollment (NP/ENH) may create additional administrative requirements.

ST = Step Therapy — if ST is shown, required prior trials must be documented or a step‑override obtained.
Program/enhanced review (ENH, TD) — follow the program's submission pathway when these flags appear.
Some products list ST explicitly in the table (examples: selected neurologic and psychiatric agents).
When ST is not fully specified in the extract, verify member‑specific rules via myHealthPartners.

Note

Verify Member Benefits

Providers must verify member‑specific benefits and coverage rules before prescribing or dispensing specialty, oncology, growth hormone, infertility, and weight‑loss medicines. Use the member's myHealthPartners account (My plan benefits) to confirm plan coverage, limits, and whether a specialty pharmacy or infusion site is required.

Verify member benefits for growth hormone (GH), infertility (INF), weight‑loss (WL), oncology (ONC) and other program‑specific medicines.
Oncology medicines often must be filled at an authorized specialty pharmacy — check the ONC flag and plan details.
Some medications may be excluded or limited depending on the member's specific plan; confirm prior to initiating therapy.

Documentation Required

Submission & Documentation Requirements

Follow the table symbols and submission requirements exactly when requesting PA, overrides, or exceptions. Documentation should include the clinical indication, pertinent labs or staging (for oncology), prior medication trials and responses, dosing and quantity rationale, and any specialty or infusion site details.

Documentation expectations: include diagnosis, prior alternatives tried, objective evidence of efficacy or intolerance, dosing, and duration rationale.
Oncology documentation (ONC) typically requires diagnosis, stage, prior lines of therapy, and regimen details.
For specialty/coagulation/IV agents include relevant weight/units, product vial/unit needs, and administration site (INF/S).
Submit PA/requests per the Requirements Limits flags shown in the table (PA, QL, ST, NP, S, ONC, WL, OP, ENH, PREV).
Requirement flag meanings: PA = prior authorization; QL = quantity limit; S = specialty; INF = infusion/administration; OP = opioid program; ACA = Affordable Care Act designation; WL = weight loss benefit; ONC = oncology.

Denial Risk

Tiering, Specialty Drugs & Denial Risk

Products on higher formulary tiers (frequently Tier 3) and many specialty biologics are commonly subject to PA and QL; lack of PA or exceeding QL can lead to claim denials. Providers should obtain PA prior to dispensing for any PA‑flagged or specialty product.

Tier 3 and specialty biologic agents often carry PA, S and QL flags (examples throughout the drug list include numerous biologic injectables and oral targeted agents).
PA and QL noncompliance may trigger claim denial or out‑of‑pocket liability for the member.
When in doubt, secure PA before the drug is dispensed to avoid coverage denial.

Denial Risk

Denial Triggers & Risk Mitigation

Specific scenarios with high denial risk: dispensing PA‑flagged products without authorization; exceeding QL without documented medical necessity; failing to follow ST or program pathways; or not using required specialty or infusion sites. These are common triggers for claim denial.

Denial triggers from table flags include missing PA, exceeding QL, failure to meet ST requirements, or not following ENH/PRE V program rules.
PA/S flags may require prior approval before dispensing; absence of approval can cause denial.
Quantity limit exceedance will be reviewed and may be denied without sufficient supporting documentation.

Policy Background & Scope

Specialty medicines are typically prescribed for chronic or complex diseases, often require additional management or monitoring, may be costly, and are usually dispensed through a specialty pharmacy or managed channel. The formulary and Pharmacy & Therapeutics Committee manage these agents with utilization controls (for example, PA, S, and quantity limits) to balance safety, effectiveness, and affordability.

Abbreviations & Key Terms

inv-96: Specialty Medicine definition — medicines prescribed by specialists for chronic/complex diseases

DefinitionSpecialty medicines: prescribed by specialists for chronic/complex diseases; often require additional management, have high cost, and are not always stocked at retail pharmacies

Dispensing requirementPrescriptions for specialty medicines must be filled at a specialty pharmacy and may be covered under a different benefit than non-specialty medicines

Provider guidanceVerify specialty benefits via the member's myHealthPartners account (Medical Plan tab)

inv-97: Formulary Abbreviations — PA, ST, AL, QL, NP, OTC, ACA definitions and abbreviations list

PAPrior Authorization Required

STStep Therapy Required

QLQuantity Limit

NPNon-Preferred (table annotation)

OTC / ACAOver-the-Counter or Affordable Care Act preventive designation

inv-98: DS — Diabetic Supplies

AbbreviationDS = Diabetic Supplies

ContextUsed as a benefit/program flag in the formulary table

ReferenceSee table header for symbol meanings

inv-99: OP — Opioid Program

AbbreviationOP = Opioid Program

ImplicationNew opioid prescriptions limited to smaller initial supply; longer therapy requires prior authorization

Provider actionCheck member-specific OP limits via myHealthPartners before prescribing

inv-100: INF — Infertility

AbbreviationINF = Infertility Benefit

ImplicationInfertility medicines may have limits or may not be covered under all plans; many entries flagged S/INF imply specialty/infusion handling

Provider actionVerify member infertility benefit via secure myHealthPartners account

inv-101: WL — Weight Loss

AbbreviationWL = Weight Loss

ImplicationWeight-loss agents may be subject to PA and QL and may not be covered under all plans

ExamplesCONTRAVE, WEGOVY, QSYMIA, ZEPBOUND are flagged WL with QL/PA

inv-102: ONC — Oncology Benefit

AbbreviationONC = Oncology Benefit

ImplicationONC indicates oncology-specific management; many ONC products require PA, specialty routing, and QL

Site-of-careOncology medicines must be filled at a specialty pharmacy per table guidance

inv-103: PA — Prior Authorization required by the plan

AbbreviationPA = Prior Authorization required by the plan

ImplicationPA-flagged products require approved authorization before coverage; lack of PA may result in denial

Provider actionSubmit PA documentation per HealthPartners criteria when PA is indicated

inv-104: QL — Quantity Limit

AbbreviationQL = Quantity Limit

DefinitionClaim-level maximum quantity allowed in specified timeframe (e.g., per 1 day or per 30 days)

Provider actionRequests above QL will be reviewed for medical necessity and may require supporting documentation

inv-105: S — Specialty

AbbreviationS = Specialty

ImplicationIndicates specialty drug requiring specialty pharmacy channel or specialty handling; may affect benefit and site-of-care

Provider actionSpecialty products often require PA and must be routed to specialty pharmacy per plan rules

inv-106: ST — Step Therapy

AbbreviationST = Step Therapy

DefinitionPlan may require trial of specified alternative medicines before covering the requested medicine at the lowest tier

Provider actionFollow ST annotations in the formulary table; submit documentation if step requirement is met or exception requested

inv-107: Prior authorization required (PA) — shorthand entry

Short formPA — Prior authorization required

UseShown as 'PA' in Requirements Limits column to indicate requirement for approval prior to coverage

ConsequenceClaims without PA may be denied

inv-108: NP — New patient or similar designation used in Requirements Limits column

Short formNP — Non-Preferred / New patient designation (table context)

UseAppears in Requirements Limits column to indicate non-preferred status or program-specific restriction

ImplicationMay influence step therapy or PA requirements

inv-109: QL — Quantity limit (numerical limits given e.g., '4 per 30 days')

Short formQL — Quantity Limit (numerical limits shown e.g., '4 per 30 days')

InterpretationNumerical QL indicates maximum units/packsets allowed in the time frame shown

ActionClaims exceeding the QL will be reviewed and may require documentation or be denied

inv-110: ONC — Oncology-specific management indicator

Short formONC — Oncology-specific management indicator

MeaningFlags agents that are oncology benefit–managed and commonly require PA, specialty routing, and QL

Provider actionProvide oncologic indication documentation when submitting PA for ONC-tagged products

inv-111: S — Specialty drug indicator

Short formS — Specialty drug indicator

MeaningIndicates specialty pharmacy channel or specialty handling is required

Operational impactSpecialty drugs may be covered under different benefit and require specialty dispensing

inv-112: ACA/OTC — Over-the-counter or ACA preventive benefit designation

Short formACA / OTC — Affordable Care Act preventive or over-the-counter designation

MeaningACA indicates preventive services covered under ACA; OTC marks non-prescription items (often with ACA implications)

ExampleLow-dose aspirin 81 mg entries marked ACA/OTC

inv-113: PA / QL / NP / ENH / S — coverage requirement flags seen throughout the table

Flags seenPA / QL / NP / ENH / S appear throughout the formulary table as requirement flags

ImplicationEach flag indicates a specific utilization control (e.g., ENH = enhanced edit; NP = non-preferred; S = specialty)

Provider actionFollow table symbol guidance and submit required documentation per flag when requesting coverage

inv-114: PA — Prior Authorization definition

DefinitionPA — Prior Authorization: coverage requires approval before the plan will cover the drug

ConsequenceLack of PA can lead to noncoverage or denial of claim

ActionSubmit PA documentation per HealthPartners prior authorization process

inv-115: S — Specialty definition

DefinitionS — Specialty: indicates the drug is managed as a specialty product and frequently dispensed via specialty pharmacy

Operational noteSpecialty designation may change benefit and site-of-care; specialty drugs often have PA and QL

Provider actionEnsure specialty routing and documentation per plan when S is indicated

inv-116: QL — Quantity Limit definition (claim-level maximum)

DefinitionQL — Quantity Limit: maximum allowed quantity in the specified timeframe (per 1 day, per 30 days etc.)

Operational detailQL values are product-specific and listed in the Requirements Limits column (e.g., 4 per 30 days, 0.75 per 1 day)

Provider actionFor requests above QL include diagnosis, alternatives tried, and evidence of efficacy/safety

inv-117: PREV — Preventive tier/flag used in formulary

DefinitionPREV — Preventive tier/flag used in formulary to denote preventive/ACA-covered items

ImplicationPREV entries may be subject to ACA coverage provisions; consult table header for details

ExampleTamoxifen listed with ONC; PREV; ACA-PA annotations in oncology section

inv-118: QL — Quantity Limit maximum allowed in specified timeframe

DefinitionQL — Quantity Limit maximum allowed in specified timeframe (e.g., per day or per 30 days)

Operational noteSome QLs are expressed as fractions per day for injectables/biologics (e.g., 0.036 per 1 day)

Provider actionClaims exceeding QL reviewed for medical necessity and may be denied without documentation

inv-119: PA — Prior Authorization (repeat definition)

DefinitionPA — Prior Authorization: requires approval before coverage (repeated for emphasis)

ImplicationMany specialty and oncology products listed with PA require documentation and prior approval

Provider actionObtain PA before dispensing PA-flagged products to avoid denial

inv-120: WL — Weight Loss program/utilization control indicator

DefinitionWL — Weight Loss: indicates agents used for weight management and subject to weight-loss program/utilization controls

ImplicationWL-tagged drugs commonly require PA and QL; coverage may vary by member plan

Provider actionVerify weight-loss benefit and submit PA where required

inv-121: Prior Authorization shorthand

ShorthandPA — Prior Authorization (shorthand used in table)

UsageDisplayed in Requirements Limits column to indicate PA requirement

Provider actionFollow PA process to request coverage

inv-122: Specialty shorthand

ShorthandS — Specialty (shorthand)

MeaningIndicates specialty channel/management required

ActionRoute to specialty pharmacy and include necessary documentation

inv-123: ACA-mandated vaccine coverage — ACA

ACAACA — Affordable Care Act (ACA-mandated vaccine coverage) flag used for preventive vaccines and related items

OTCOTC — Over-the-Counter designation; OTC items generally not covered unless noted (some ACA OTC items listed)

ExampleSHINGRIX and other vaccines marked ACA; SHINGRIX QL 1 per 30 days

inv-124: Quantity Limit shorthand (QL)

Short formQL — Quantity Limit (shorthand)

MeaningIndicates a maximum allowed quantity per time period (e.g., 3 per 30 days)

Provider actionProvide justification for requests exceeding QL

inv-125: QL — example definition and usage

Example usageQL used to limit dispensing (see many oncology and specialty entries with QL values)

InterpretationNumerical QL values may be per day or per period; fractional/day QLs used for pens/biologics

ActionReview product-specific QL when assessing claim or PA request

inv-126: ACA — requirement/limit label used in the formulary

ACA flagACA — requirement/limit label used in formulary for preventive items and some contraceptives

ImplicationACA entries may be covered without cost-sharing per plan guidance; check table header for full meaning

ExampleMany contraceptives and vaccines marked ACA in the table

Step Therapy Listings & Indicators

Step therapy occurrence	Summary
Step therapy requires trying specified alternative medicines before coverage of the requested medicine; approval required if alternatives not tried.
Formulary entries annotated 'ST' indicate step therapy applies to that product; details of required prior agents are provided in the full formulary table.

ST annotation context	Summary
'ST' (Step Therapy) appears in the abbreviation key; ST may require trying preferred drugs first as annotated in the formulary.

Oncology entries & ST	Summary
Many antineoplastic entries include ONC/TD/S flags; explicit step-therapy sequences for oncology agents are not provided in this extract.

Products with ST/S/PA flags	Summary
Some products (e.g., RYTARY) are listed with 'ST'; other products show S and PA indicating specialty and prior authorization alongside step-like requirements.

Specialty/high-tier agents	Summary
Several specialty/high-tier agents are assigned PA and NP or QL flags, indicating review or step/restriction requirements before coverage.

TRINTELLIX	Summary
TRINTELLIX is listed with 'Requirements Limits = ST' (step therapy) along with NP and QL in the formulary extract.

ENH edits	Summary
Some oral anticoagulant entries show 'ENH' (enhanced edits) and QL which may implement utilization controls; explicit step edit details are not provided here.

REPATHA	Summary
REPATHA presentations (Pushtronex, SureClick) are shown with 'Requirements Limits = ST' indicating step therapy applies to PCSK9 inhibitor coverage.

ALTABAX	Summary
ALTABAX topical ointment is listed with 'Requirements Limits = ST', indicating a step therapy requirement per the formulary.

SC / PREV flags	Summary
Some products include SC and PREV flags (e.g., smoking deterrents, certain insulins) indicating program-level or preventive/step considerations in coverage.

GLM/GLP-1/T2DM agents	Summary
Selected GLM/GLP-1/T2DM agents (e.g., MOUNJARO, OZEMPIC, RYBELSUS) are marked 'PREV' indicating preventive/prior therapy considerations; may imply prior therapy or step requirements.

NP and other flags	Summary
The extract shows 'NP' and other requirement flags in the table but does not provide explicit step-therapy sequences or algorithms within these chunks.

Step therapy rules	Summary
Step therapy rules are not specified for the products in these chunks; 'NP' may imply non-preferred or step requirements elsewhere in the full formulary.

Quantity Limits & Per-Product Examples

inv-140: unspecified (formulary-wide) — quantity limit applies; requests above limit reviewed

Formulary-wide QL ruleQuantity limit applies; requests above the limit will be reviewed for medical necessity (diagnosis, alternatives tried, evidence of efficacy/safety)

Provider actionInclude clinical documentation when requesting overrides for quantities above QL

Denial riskRequests without supporting documentation may be denied

inv-141: trial drugs — first 6 fills may be limited to less than a month supply

TD ruleTrial Drug Program: first 6 fills may be limited to less than a month supply

PurposeUsed for new prescriptions with side-effect risk, high cost, or high waste potential

Next stepsIf effective, remainder of month supply provided; copay guidance applies

inv-142: opioids (new prescriptions) — initial prescription limited to smaller supply

Opioid initial supplyNew opioid prescriptions limited to smaller initial supply; longer therapy requires prior authorization

Examples of opioid QLsHydrocodone ER/IR and other opioids have QL per day (e.g., QL 2 per 1 day for some ER formulations)

Provider actionVerify member opioid program limits and PA requirements via myHealthPartners prior to dispensing

inv-143: nystatin oral suspension 100,000 unit/ml — QL 480

Productnystatin oral suspension 100,000 unit/ml

Quantity limitQL 480 per 30 days

TierDrug Tier = 2 (as listed)

inv-144: EDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG — QL 6

ProductEDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG

Quantity limitQL 6 per 1 day

TierDrug Tier = 3 (as listed)

inv-145: PAXLOVID 150 MG dose pack — QL 4

ProductPAXLOVID 150 mg dose pack

Quantity limitQL 4 per 1 day (dose pack level)

ProductPAXLOVID 300 mg dose pack

Quantity limitQL 6 per 1 day (dose pack level)

inv-146: PAXLOVID 300 MG dose pack — QL 6

ProductPAXLOVID 300 mg dose pack

Quantity limitQL 6 per 1 day (dose pack level)

TierDrug Tier = 3

inv-147: YEZTUGO — QL 4

ProductYEZTUGO oral tablet 300 mg

Quantity limitQL 4 per 30 days

FlagsRequirements Limits include S; ACA; QL

inv-148: ALINIA (nitazoxanide) — QL 180

ProductALINIA (nitazoxanide) oral suspension 100 mg/5 ml

Quantity limitQL 180 per 30 days

FlagsRequirements Limits = PA; NP; QL

inv-149: linezolid — QL 2

ProductLinezolid oral tablet 600 mg

Quantity limitQL 2 per day

FlagsRequirements Limits include QL (2 per day); PA for suspension formulations

Specialty Pharmacy & Infusion Requirements

Note

Policy Summary

PayerHealthPartners

PolicyHealthPartners Formulary (2026 Drug List) — Coverage & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization when a product is flagged 'PA' and submit required documentation per the formulary table.

SourceLink

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HealthPartners Formulary (2026 Drug List) — Coverage & Utilization Controls

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Policy Summary

PayerHealthPartners

PolicyHealthPartners Formulary (2026 Drug List) — Coverage & Utilization Controls

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization when a product is flagged 'PA' and submit required documentation per the formulary table.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026Formulary year

QuarterlyReview frequency

PA, ST, AL, QLCommon limits

TD: first 6 fillsTrial Drug Program

OTC not coveredOTC coverage stance

Formulary Coverage & Requirement Flags

Formulary coverage with utilization management markers

Coverage is indicated by drug presence on the formulary with utilization management markers; specific medical-necessity decision trees are not included in this extract.

Formulary presence: Drugs listed with a Drug Tier value are covered on the formulary subject to the Requirements Limits codes shown (PA, NP, QL, S, ONC, TD, ACA).

Full clinical coverage criteria and indications are in other sections not included here

Coverage controls by requirement flags

Coverage and utilization controls apply as indicated by requirement flags next to each product line.

Specialty/coagulation products: Products listed with 'PA; S' require prior authorization and specialty management; coverage is contingent on approval and any specialty program enrollment.

Examples include intravenous coagulation factor products (ADVATE, ADYNOVATE, ALPHANATE, ALPHANINE, ELOCTATE) shown with PA; S.

Noncompliant claims may require override or be denied.

Exact coverage implications are defined at the table header (not included in these chunks).

Formulary coverage indications

Coverage is indicated by formulary inclusion with an assigned Drug Tier and 'Requirements Limits' label (for example, ACA); some agents also show OTC status and quantity limits.

Formulary inclusion: Drug appears on the formulary with a specified Drug Tier and Requirements Limits label (commonly 'ACA' for contraceptives/vaccines in this segment).

See the full table header for definitions of requirement/limit labels and ACA/OTC implications.

Codes, Abbreviations & Program Limits

Formulary Drug Codes (sample entries)NDC

ciprofloxacin_oral_tablet_250_mg	ciprofloxacin oral tablet 250 mg
ciprofloxacin_oral_tablet_500_mg	ciprofloxacin oral tablet 500 mg
ciprofloxacin_oral_tablet_750_mg	ciprofloxacin oral tablet 750 mg
valganciclovir_oral_tablet_450_mg	valganciclovir oral tablet 450 mg
viread_oral_tablet_200_mg	VIREAD oral tablet 200 mg
cefadroxil_oral_tablet_1_g	cefadroxil oral tablet 1 gram

Requirement/Limit codes used in tablemixed

PA	Prior Authorization
NP	Network Pharmacy / Not Preferred
QL	Quantity Limit (examples: QL (4 per 30 days), QL (180 per 30 days), QL (2 per day), QL (6 per 30 days))
S	Specialty
ONC	Oncology
TD	Trial Drug Program (first fills may be limited)
ENH	Enhanced benefit / special packaging
ACA	ACA preventive benefit
PREV	Preventive