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HealthPartners 2026 Formulary — Coverage Criteria (Pharmacy & Specialty Drugs)

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This document is the HealthPartners drug list (formulary) effective January 1, 2026, describing covered medicines, tiers, specialty drug rules, and common formulary restrictions for HealthPartners members and providers.

Policy Summary

PayerHealthPartners

PolicyFormulary coverage criteria — Pharmacy & Specialty Drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateMar 1, 2026

Key ActionObtain prior authorization when a drug is listed with 'PA' before dispensing to ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-01-01formulary effective date

Quarterlyreview frequency

PA, ST, QL, Srestriction abbreviations

PA, QL, ACArequirement flags present

20+drug entries shown

Coverage & Utilization Management

Formulary Utilization Management Rules

Coverage and utilization management rules apply as follows

Formulary governance and review: The Pharmacy and Therapeutics Committee reviews the drug list quarterly focusing on safety, effectiveness, and affordability.

Prior authorization: Drugs listed with PA require prior authorization per HealthPartners criteria before pharmacy benefit coverage is granted.

Refer to HealthPartners prior authorization process and form when submitting requests.

Step therapy: Drugs listed with ST require trial and documented failure of specified alternatives prior to coverage at preferred cost-sharing.

When 'ST' is present providers must document prior therapies tried and outcomes.

Policy Summary

PayerHealthPartners

PolicyFormulary coverage criteria — Pharmacy & Specialty Drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateMar 1, 2026

Key ActionObtain prior authorization when a drug is listed with 'PA' before dispensing to ensure coverage.

SourceLink

On This Page

Quantity limits (QL) restrict the amount dispensed per time period; requests exceeding QL will be reviewed for medical necessity and require documentation of diagnosis, alternatives tried, prior use within limits, and evidence of efficacy/safety at the requested quantity.

Examples of QL values and documentation expectations are provided in the formulary entries.

Trial Drug Program: Selected new prescriptions may be managed under a Trial Drug Program (TD): initial fills may be limited (first 6 fills limited to less than a month supply) to assess tolerability and waste risk.

If tolerated and effective, subsequent fills may be adjusted per plan rules.

Formulary table coverage rules

Coverage and utilization controls for listed adjunctive agents as table entries

Table-based coverage rules: Each product row includes a Tier assignment and a Requirements Limits field using abbreviations (ACA, PA, ST, QL, S, TD, OP, $). Coverage follows those designations: PA = prior authorization required; QL = limited to the specified quantity/frequency; S = managed as a specialty product; ST = step therapy applies; ACA flags indicate ACA/preventive or ACA-related coverage rules.

This node captures table-level utilization logic rather than patient-level clinical criteria.

Topical and adjunctive agent controls: Topical antifungals and other adjunctive agents in the table may carry PA or QL flags (examples: ciclopirox suspension QL (2 per 1 day); luliconazole PA; oxiconazole PA; klayesta QL (240 per 30 days)).

Providers should follow the Requirements Limits entry for each product when seeking coverage.

Formulary listing rules

Formulary coverage and requirements shown per product

Formulary entry: Each listed product includes product name, strength/form, Tier Drug assignment, and Requirements Limits (examples shown: ACA, PA, QL, S, TD). Coverage and benefit application follow the listed Tier and Requirements Limits for that product.

This excerpt provides listing-level coverage designations only and does not include clinical necessity decision trees.

Contraceptives and preventive products: Many contraceptives and preventive vaccines are designated ACA (Affordable Care Act) and may be covered per ACA rules; some ACA entries also include QL (examples: TRUSTEX condoms QL 60 per 30 days; ANNOVERA QL 1 per 273 days; levonorgestrel QL 3 per 30 days).

Providers should reference the product-specific Requirements Limits for quantity/frequency and any PA exceptions.

Some specialty medicines listed in this formulary are managed under a different benefit and must be dispensed through a specialty pharmacy. Coverage for these products is plan-dependent; members and providers should check the member's plan benefits (myHealthPartners account, Medical Plan tab) to confirm whether a specialty benefit applies and whether specialty pharmacy dispensing is required.

The excerpt does not provide explicit clinical exclusion criteria. Instead, the listing is a product-level table that shows formulary Tier assignments and Requirements Limits flags (examples include PA, QL, S), which implement utilization controls for each product rather than listing clinical exclusions.

Administrative flags and Requirements/Limits codes appearing in the table (for example, PA, S, QL, ACA) indicate that coverage conditions, documentation needs, or specialty handling are defined elsewhere in the full formulary and authorization process. This excerpt does not reproduce the full clinical criteria tied to those administrative flags.

Within the provided excerpt there are no explicit clinical exclusion statements. The document portion shown lists product-level utilization controls and administrative designations but does not specify conditions that would categorically exclude a product from coverage.

The excerpt does not identify any products as explicitly not medically necessary. Coverage designations in this section are limited to formulary tiers and administrative requirement flags (e.g., PA, QL, ACA) rather than 'not medically necessary' determinations.

No statements in the excerpt declare specific drugs or classes to be not medically necessary. The table entries focus on utilization controls (tiering, prior authorization, quantity limits, specialty designation) and reference a legend and full criteria elsewhere for detailed medical necessity decisions.

Drug Entries & Codes

Selected formulary drug entries shownNDC | mixed

CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG	Tier Drug = 3; Requirements Limits = PA
NOXAFIL ORAL SUSP,DELAYED RELEASE FOR RECON 300 MG	Tier Drug = 2; Requirements Limits = PA
nystatin oral suspension 100,000 unit/1	Requirements Limits = QL (480 per 30 days)
posaconazole oral suspension 200 ml (40 mg/ml)	Tier Drug = 1; Requirements Limits = PA
posaconazole oral tablet,delayed release (drlec) 100 mg	Requirements Limits = PA
voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)	Requirements Limits = PA

Formulary drug entries (partial)NDC/mixed

amoxicillin oral suspension	multiple strengths/formulations listed (125 ml, 200 ml, 250 ml; 400 mg/5 ml)
amoxicillin oral tablet	500 mg, 875 mg
amoxicillin-pot clavulanate oral tablet	250-125 mg, 500-125 mg, 875-125 mg
penicillin V potassium oral tablet	250 mg, 500 mg
ciprofloxacin hcl oral tablet	250 mg, 500 mg, 750 mg
levofloxacin oral tablet	250 mg, 500 mg, 750 mg
doxycycline monohydrate oral capsule	100 mg, 50 mg
nitrofurantoin macrocrystal oral capsule	100 mg, 25 mg, 50 mg
vancomycin oral capsule	125 mg, 250 mg

Antineoplastic & immunosuppressant drug entriesNDC/mixed

abiraterone oral tablet	250 mg, 500 mg
bicalutamide oral tablet	50 mg
capecitabine oral tablet	150 mg, 500 mg
dasatinib oral tablet	100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg
everolimus (antineoplastic) oral tablet	10 mg, 2.5 mg, 5 mg, 7.5 mg
ibrance (palbociclib) oral capsule/tablet	75 mg, 100 mg, 125 mg
lenalidomide oral capsule	2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg, 25 mg
imatinib oral tablet	100 mg, 400 mg
nilotinib oral capsule	50 mg (and other strengths)
pazopanib oral tablet	200 mg

1–10 of 13

1/2

Selected oral anticoagulant product entriesmixed

ELIQUIS ORAL TABLET 2.5 MG	ELIQUIS ORAL TABLET 2.5 MG (Requirements Limits = QL (2 per 1 day))
ELIQUIS ORAL TABLET 5 MG	ELIQUIS ORAL TABLET 5 MG (Requirements Limits = QL (2.467 per 1 day))
XARELTO ORAL TABLET 10 MG	XARELTO ORAL TABLET 10 MG (Requirements Limits = QL (1 per 1 day))
XARELTO ORAL TABLET 15 MG	XARELTO ORAL TABLET 15 MG (Requirements Limits = QL (2 per 1 day))

Coagulation factor and high-cost injectables (selected)mixedCovered

ADVATE INTRA VENOUS RECON SOLN	ADVATE INTRA VENOUS RECON SOLN (multiple unit sizes) Requirements Limits = PA; S
ADYNOVATE INTRA VENOUS SOLUTION	ADYNOVATE INTRA VENOUS SOLUTION (multiple unit sizes) Requirements Limits = PA; S
AFSTYLA INTRA VENOUS RECON SOLN	AFSTYLA INTRA VENOUS RECON SOLN (multiple unit ranges) Requirements Limits = PA; S
ALPHANATE INTRA VENOUS RECON SOLN	ALPHANATE INTRA VENOUS RECON SOLN (multiple unit sizes) Requirements Limits = PA; S

Common oral antihypertensivesmixedCovered

lisinopril oral tablet 5 mg, 2.5 mg, 10 mg, 20 mg, 30 mg, 40 mg	ACE inhibitor oral tablet strengths listed
losartan oral tablet 25 mg, 50 mg, 100 mg	ARB oral tablet strengths listed
metoprolol succinate oral tablet extended release 24 hr 25 mg, 100 mg, 200 mg	Beta blocker ER strengths listed

Thyroid hormone productsNDC-like/plain

euthyrox oral tablet 25 mcg,50 mcg,75 mcg,88 mcg,100 mcg,112 mcg,125 mcg,137 mcg,150 mcg,175 mcg,200 mcg	Euthyrox (levothyroxine) oral tablet strengths listed
levothyroxine oral tablet 25 mcg,50 mcg,75 mcg,88 mcg,100 mcg,112 mcg,125 mcg,137 mcg,150 mcg,175 mcg,200 mcg,300 mcg	Levothyroxine oral tablet strengths listed
liothyronine oral tablet 5 mcg,25 mcg,50 mcg	Liothyronine oral tablet strengths listed
SYNTHROID oral tablet 25 mcg,50 mcg,75 mcg,88 mcg,100 mcg,112 mcg,125 mcg,137 mcg,150 mcg,175 mcg,200 mcg,300 mcg	Synthroid (levothyroxine) strengths listed

Gastroenterology agentsNDC-like/plain

dicyclomine oral capsule 10 mg; dicyclomine oral tablet 20 mg; dicyclomine oral solution 10 mg/5 ml	Dicyclomine formulations
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml; diphenoxylate-atropine oral tablet 2.5-0.025 mg	Diphenoxylate-atropine formulations (QL specified)
glycopyrrolate oral solution 1 mg/5 ml; glycopyrrolate oral tablet 2 mg	Glycopyrrolate formulations
loperamide oral capsule 2 mg	Loperamide
metoclopramide hcl oral solution; metoclopramide hcl oral tablet 5 mg,10 mg	Metoclopramide formulations

Selected specialty gastroenterology agentsNDC-like/plain

alosetron oral tablet 0.5 mg,1 mg	Alosetron (PA required)
alvimopan oral capsule 12 mg	Alvimopan (PA required)
CIMZIA subcutaneous syringe kit 400 mg/2 mL (200 mg/mL x2)	CIMZIA (PA; S; QL indicated)
CREON oral capsule DR/EC multiple units (various strengths)	Pancrelipase formulations
LINZESS oral capsule 72 mcg,145 mcg,290 mcg	Linaclotide (QL indicated)
MOVANTIK oral tablet 12.5 mg,25 mg	Movantik (PA; QL)

Immunology/biotech and vaccinesNDC-like/plain

ARANESP injection solution and syringes (various mcg/mL)	Erythropoiesis-stimulating agent
GRANIX subcutaneous solution 300 mcg/mL; GRANIX syringe 300	G-CSF product
RETACRIT injection solution (various unit concentrations)	Erythropoietin agent
PEGASYS subcutaneous solution 180 mcg/mL; PEGASYS syringe 180	Peginterferon
Multiple vaccines (ABRYSVO, AREXVY, BEXSERO, ADACEL, AFLURIA, FLUCELVAX, FLUZONE, GARDASIL9, etc.)	Vaccines with ACA requirement noted for many

No billing codes in excerptmixed

No codes listed

Nystatin quantity limit example — 480 per 30 days

Nystatin (oral suspension)Quantity limit = 480 per 30 days

NOXAFIL (posaconazole) oral suspension 300 mg (recon)Requirements Limits = PA

posaconazole oral tablet, delayed release (DRLEC) 100 mgRequirements Limits = PA

voriconazole oral suspension/tabletRequirements Limits = PA

nystatin oral tablet 500,000 unitRequirements Limits = (no QL listed)

Quantity limit examples — 480/30d; 20/30d; 180/30d; 6/1d; 5/1d

Example QLs: 480/30dnystatin oral suspension QL = 480 per 30 days

Example QLs: 20/30doseltamivir oral suspension QL = 180 per 30 days; certain oseltamivir entries show QL (10 per 30 days) for specific strengths

Example QLs: 180/30doseltamivir oral suspension for reconstitution QL = 180 per 30 days

Example QLs: 6/1dPAXLOVID dose pack Requirements Limits = QL per 1 day (dose-pack QL per 1 day) / some oral antimicrobials show per-day QLs

Example QLs: 5/1dmultiple benzodiazepine formulations and other agents list per-day QLs (e.g., lorazepam, alprazolam entries show per-day QLs)

QL examples — tetracycline QL 56/30d; fosfomycin QL 3/30d

Tetracycline oral capsuleRequirements Limits = QL (56 per 30 days)

Fosfomycin tromethamine oral packet 3 gRequirements Limits = QL (3 per 30 days)

Doxycycline / minocycline groupSome tetracycline-class entries show QL designations (see tetracycline QL 56/30d)

Daily equivalent QL — IBRANCE 0.75/day; POMALYST 0.75/day (examples)

IBRANCE (palbociclib)Requirements Limits = QL (0.75 per 1 day) as daily-equivalent QL

POMALYST and other oncology agentsExample daily-equivalent QLs are applied (POMALYST QL shown as 0.75 per 1 day in oncology list)

ELIQUIS DVT-PE dosing pack (example of daily equivalent QL)ELIQUIS DVT-PE TREAT 30D START pack QL = 2.467 per 1 day (daily-equivalent pack QL)

Quantity limits examples list (various per-day limits shown)

Multiple per-day QL examplesExamples across psychotropic, analgesic and stimulant classes include QLs such as 8 per 1 day, 4 per 1 day, 3 per 1 day, 1 per 1 day, 6 per 1 day, 2 per 1 day

Tramadol formulationsTRAMADOL ER/IR entries show QLs (e.g., ER 100 mg QL 3/day; IR 50 mg OP QL 8/day)

NUCYNTA (tapentadol)NUCYNTA QLs: 50 mg QL 4/day; 75 mg QL 3/day; 100 mg QL 2/day

Quantity limits examples — sodium oxybate 18/day; AVONEX 0.036/day; MAVENCLAD pack entries

Sodium oxybate oral solution 500 mg/mLRequirements Limits = QL (18 per 1 day)

AVONEX intramuscular syringe 30 mcg/0.5 mLRequirements Limits = PA; S; QL (0.036 per 1 day)

MAVENCLAD tablet packsRequirements Limits = PA; $ or PA; S depending on pack — QL varies by pack entries

Example QL values — ELIQUIS 2/day; ELIQUIS DVT-PE TREAT 2.467/day; enoxaparin syringe variations

ELIQUIS (apixaban) oral tablet 2.5 mgRequirements Limits = QL (2 per 1 day)

ELIQUIS DVT-PE Treat 30d start pack 5 mgRequirements Limits = QL (2.467 per 1 day) — example of pack-level daily-equivalent QL

Enoxaparin subcutaneous syringe formulationsRequirements Limits = S; QL values vary by formulation (e.g., QL 2 per 1 day; QL 0.8 per 1 day; QL 1.2 per 1 day)

Quantity limits examples — variety including 2/day, 240/30d, 15/30d, 6/1d

Topical/other QL examples (varied)Examples include QL (2 per 1 day), QL (240 per 30 days), QL (15 per 30 days), QL (6 per 1 day) depending on product

ciclopirox topical suspension 0.77%Requirements Limits = QL (2 per 1 day)

klayesta topical powder / nystatin topical powderRequirements Limits = QL (240 per 30 days)

ANNOVERA vaginal ringRequirements Limits = QL (1 per 273 days)

levonorgestrel (emergency contraceptives)Requirements Limits = ACA; QL (3 per 30 days)

Quantity limits examples — diphenoxylate-atropine liquid 40/1d; tablets 8/1d; dronabinol varies

Diphenoxylate‑atropine oral liquid 2.5-0.025 mg/5 mLRequirements Limits = QL (40 per 1 day)

Diphenoxylate‑atropine oral tablet 2.5-0.025 mgRequirements Limits = QL (8 per 1 day)

Dronabinol oral capsule (various strengths)Requirements Limits = QL (2–8 per 1 day depending on strength)

Quantity limits examples — ANNOVERA 1 per 273 days; levonorgestrel 3/30d; ELLA 3/30d

ANNOVERA vaginal ringRequirements Limits = ACA; QL (1 per 273 days)

Levonorgestrel oral tablet 1.5 mg (emergency contraception)Requirements Limits = ACA; QL (3 per 30 days)

ELLA (ulipristal acetate) oral tablet 30 mgRequirements Limits = ACA; QL (3 per 30 days)

Prior Authorization, Step Therapy & Documentation

Prior Authorization

Prior authorization required for PA-designated products

Certain formulary medicines require prior authorization before pharmacy benefit coverage is granted; for products designated ACA‑PA, prior authorization is used to confirm Affordable Care Act program requirements are met.

Obtain and submit HealthPartners prior authorization when the product is listed with 'PA' in Requirements/Limits.
For ACA-designated products, use PA to confirm ACA program criteria are satisfied.

Prior Authorization

HARVONI — prior authorization and specialty handling

HARVONI is listed with a prior authorization requirement and specialty handling; providers must submit a PA request before coverage.

HARVONI oral pellets/tablet entries show 'Requirements Limits = PA; S' — submit PA and supporting clinical information.

Prior Authorization

LEDIPASVIR‑SOFOSBUVIR — PA required

Ledipasvir‑sofosbuvir (LEDIPASVIR‑SOFOSBUVIR) is listed with prior authorization and specialty designation; a PA must be obtained prior to benefit coverage.

LEDIPASVIR‑SOFOSBUVIR entry shows 'Requirements Limits = PA; S' — submit PA per HealthPartners process.

Prior Authorization

Selected antivirals and high‑cost agents require PA

Several high-cost antivirals and other agents (e.g., PREVYMIS) are annotated with PA; providers must request prior authorization for these products.

PREVYMIS entry specifies 'Requirements Limits = PA' — obtain PA prior to dispensing.
PAXLOVID and other antiviral dose packs may also carry QL or PA requirements; consult the product entry.

Prior Authorization

Prior authorization required for many listed products

Numerous drug entries in the formulary table show 'Requirements Limits = PA', indicating prior authorization must be obtained before coverage for those listed medicines.

Examples include oncology adjunctive agents and many targeted therapies listed with PA; submit PA using HealthPartners' prior authorization form.

Prior Authorization

PA required for multiple oncology agents

Many oncology agents require prior authorization and oncology program flags (ONC/TD/S) — providers must obtain PA and follow program requirements for these agents.

Examples: ROZLYTREK, TAFINLAR, VERZENIO, XPOVIO and other oncology drugs list 'PA; ONC; S' — submit PA and any oncology program documentation.

Prior Authorization

PA required for selected adjunctive neurologic agents

Selected adjunctive neurologic/movement‑disorder agents (examples: EVRYSDI, INGREZZA, ZEPOSIA, tetrabenazine) are marked 'PA' and often 'S' or QL; prior authorization and specialty handling are required.

INGREZZA initiation pack: 'PA; S; QL (28 per 273 days)' — submit PA and document indication and dosing.
EVRYSDI: 'PA; S' — submit PA per HealthPartners process.

Prior Authorization

Opioid formulations — prior authorization required

Extended‑release and certain high‑strength opioid products include PA and QL entries; providers must obtain prior authorization for those opioid formulations.

Examples: ER opioid products and specific hydrocodone/hydromorphone formulations list 'PA; QL' — submit PA to avoid claim denial.

Prior Authorization

PA required for many adjunctive agents — submit PA

Numerous adjunctive agents across categories are subject to prior authorization as indicated by 'PA' in the Requirements/Limits column; providers must submit PA requests for these medications.

Providers should review each product entry for 'PA' and follow HealthPartners' PA submission process.

Prior Authorization

PA required for select psychiatric/CNS agents

Several psychotropic and CNS agents list PA in their Requirements/Limits field (examples include REXULTI, SECUADO); prior authorization must be obtained when PA is indicated.

REXULTI and SECUADO entries show 'PA' — include required clinical documentation with PA submission.

Prior Authorization

PA required for select coagulation and specialty injectables

Selected high‑cost coagulation factor products and specialty injectables are marked 'PA; S' — prior authorization and specialty distribution requirements must be met before coverage.

Examples: ADVATE, ADYNOVATE, AFSTYLA, ALPHANATE list 'PA; S' — submit PA and ensure specialty pharmacy or infusion site processes are followed.

Prior Authorization

Topical agents — PA required where annotated

Multiple topical agents are listed with 'PA' or QL designations; prior authorization is required for products annotated with PA.

Examples: ERTACZO topical cream 2%, LULICONAZOLE 1%, naftifine topical products and oxiconazole are marked with PA and/or QL — submit PA when shown.

Prior Authorization

PA required for specified specialty oral agents

Certain specialty oral agents (e.g., deferasirox, deferiprone, FERRIPROX, TAVNEOS, PYRUKYND) are annotated 'PA' and often specialty‑flagged; providers must obtain PA and supply specialty documentation.

Deferasirox entries: 'PA; TD; $' or 'PA; TD; S' — submit detailed PA documentation per payer requirements.
TAVNEOS: 'PA; S; QL (6 per 1 day)' — PA plus quantity justification required.

Prior Authorization

PA required for listed specialty and some insulin products

Prior authorization is required for certain specialty therapies and some insulin products (e.g., some insulin aspart presentations, CERDELGA, GALAFOLD, ISTURISA); obtain PA when the product entry shows 'PA'.

Insulin aspart cartridge entry shows 'PA' — submit PA per HealthPartners process.
GALAFOLD entry: 'PA; S; QL (0.5 per 1 day)' — include supporting documentation with PA.

Prior Authorization

Prior authorization required for various additional agents

Multiple other agents across formulary sections are annotated with 'PA'; providers must obtain prior authorization for any drug entry showing PA in Requirements/Limits.

Examples include alosetron and alvimopan (PA) and CIMZIA (PA; S; QL) — submit PA and documentation as indicated.

Prior Authorization

Products requiring prior authorization (allergens, biologics)

Allergen sublingual immunotherapy/tablet products and many biologics are listed with 'PA' — prior authorization must be obtained for these products.

Examples: GRASTEK, RAGWITEK, ODACTRA and biologics (ADALIMUMAB variants, ACTEMRA, ENBREL, ORENCIA) show 'PA' — include diagnosis, prior treatments, and dosing in PA submission.

Prior Authorization

PA required for select gynecologic/hormone products

Certain estrogen/progestin and gynecologic products (e.g., BIJUVA, DUAVEE, MYFEMBREE, ORIAHNN, OSPHENA) are listed with 'PA'; providers must obtain prior authorization when PA is indicated.

BIJUVA and DUAVEE entries show 'PA' — submit PA and clinical rationale for coverage.

Prior Authorization

PA required for select ophthalmic agents

Select ophthalmic agents (e.g., CYSTADROPS, CYSTARAN, AZASITE, BESIVANCE, levofloxacin ophthalmic) are annotated with prior authorization and/or quantity limits; providers must obtain PA when shown.

CYSTADROPS: 'PA; S; QL (5 per 30 days)'; CYSTARAN: 'PA; S; QL (15 per 30 days)'.
AZASITE and BESIVANCE entries show 'PA' — submit PA per payer requirements.

Step Therapy

Step therapy — complete required trials before coverage

Some medicines require step therapy (ST): the member must have tried and failed specified alternatives before coverage at preferred cost‑sharing; follow step therapy requirements where 'ST' or 'S' is indicated.

TRINTELLIX and certain zolpidem formulations are marked 'ST' — ensure documented trial/failure of alternatives before PA or coverage.
Products marked 'S' (e.g., PALFORZIA; ISTURISA; GALAFOLD) may indicate step therapy requirements — include evidence of required prior therapies when submitting PA.

Note

Tiering may imply step preference — confirm product‑level rules

Some high‑tier products are assigned tiers that may imply preferred sequencing, but explicit step sequences are not always provided in this excerpt; providers should check the specific product entry and PA criteria.

Tier 4 antiviral agents and oncology entries often carry PA/ONC flags — review product-level notes for step or program requirements.

Note

Program flags (ONC/TD/S) — follow managed pathways

Program flags (ONC, TD, S) beside entries indicate managed pathways (e.g., oncology programs, therapy‑directed programs or specialty management); follow program/step edit requirements when present.

ONC and TD flags signal oncology/program-directed management; include program documentation with prior authorization requests.

Documentation Required

Quantity limit overrides — required documentation and denial risk

Where a product entry exceeds a listed quantity limit, requests above the QL will be reviewed for medical necessity and may be denied if the required justification (diagnosis, alternatives tried, prior use, and evidence) is not provided.

Document diagnosis, prior therapies tried, prior use within QL, and clinical rationale/evidence when requesting QL overrides.
Examples of QL entries include oseltamivir (20/30d), PAXLOVID (QL per 1 day), and many biologics with per‑day equivalents.

Denial Risk

Prior authorization/step/QL omissions — denial risk

Requests missing required prior authorization, step‑therapy completion, or quantity‑limit justification are at risk for denial — ensure PA, ST and QL requirements shown in Requirements/Limits are satisfied before submitting claims.

Drugs flagged with PA, ST, QL, S or ONC may be denied if requirements are not met (examples: oncology agents, REXULTI, TRINTELLIX, opioid ER products).

Documentation Required

PA documentation — submit payer form and supporting clinical info

When a product is marked 'PA' or shows Requirements/Limits flags (PA, S, QL, ONC, TD), clinicians must submit HealthPartners' prior authorization form and supporting clinical information.

Include diagnosis, prior treatment history, dosing, and evidence of medical necessity on the PA form.
For biologics/rheumatology agents include prior treatments, dosing frequency and rationale to support PA.

Documentation Required

PA documentation for biologics and specialty agents

Biologics and other specialty therapies with 'PA; S; QL' designations require prior authorization plus documentation of prior therapies and dosing to support the request; providers should include these details in PA submissions.

Examples: ADALIMUMAB variants, ACTEMRA, ENBREL, ORENCIA show 'PA; S; QL' — include diagnosis, prior treatments, and dosing schedule in PA.

Documentation Required

Documentation required for QL overrides

For requests that exceed quantity limits, provide documentation of the diagnosis, alternatives tried, prior use within limits, and evidence of efficacy/safety at the requested quantity to support an override.

Documentation for QL overrides should clearly state why the higher quantity is clinically necessary and reference prior treatment response.

Note

Specialty handling/site‑of‑care — follow S/ONC flags

Products annotated with 'S' or 'PA' may require specialty dispensing or site‑of‑care handling (specialty pharmacy or infusion center); follow the specialty distribution/site instructions shown in the product entry.

Oncology and many coagulation factor products flagged 'S' are typically dispensed via specialty pharmacy or require infusion‑center processes.

Denial Risk

PA and QL noncompliance — potential claim denial

Claims for drugs with PA and QL flags may be denied if prior authorization is not obtained or if quantity limits are exceeded without justification; verify PA and QL status on the formulary entry before prescribing.

Examples: SHINGRIX QL 1/30d and condoms QL 60/30d — requests above these limits may be denied without documentation.
Claims for drugs showing 'PA' will be processed only after an approved authorization is on file.

Documentation Required

Ophthalmic agents — PA plus quantity‑limit documentation required

Some ophthalmic products include both PA and QL (e.g., CYSTADROPS QL 5/30d; CYSTARAN QL 15/30d); obtain PA and document quantity justification when submitting requests for these agents.

CYSTADROPS: 'PA; S; QL (5 per 30 days)'; CYSTARAN: 'PA; S; QL (15 per 30 days)' — include QL justification and PA documentation.

Note

Initial Coverage & Prior Authorization Examples

Initial coverage and prior auth flags (examples)

Formulary entries and requirements (partial list); many agents require PA or have QL

Examples of PA and QL requirements: NUCYNTA oral tablets (50, 75, 100 mg) are listed with Requirements Limits = PA; OP; QL (4/day for 50 mg; 3/day for 75 mg; 2/day for 100 mg).

PA and QL present — submit PA and adhere to QL on claims.

Tramadol formulations: Multiple tramadol ER/IR formulations are listed with Requirements Limits = PA and QL (examples: ER formulations with QL (1–3 per day) and IR formulations with OP or QL limits).

PA required for many ER formulations; daily QL must be observed.

Opioid & opioid-analogue controls: Several opioid products are annotated with PA, OP and QL flags indicating prior authorization, opioid program handling, and quantity limits that may restrict coverage if not met.

Failure to meet PA/OP/QL may result in claim denial.

Psychotropic and other examples: Selected psychotherapeutic agents and other adjunctive drugs may carry QL or PA flags (e.g., alprazolam QL (6 per 1 day); certain disintegrating formulations require PA).

Follow product-specific Requirements Limits when requesting coverage.

Smoking cessation products

Products used for smoking cessation are listed with program and coverage flags

Smoking cessation coverage notes: Smoking cessation products (nicotine gum/lozenges/patch, nicotrol NS, bupropion SR, varenicline) are marked SC; ACA indicating coverage under the smoking cessation/ACA rules. Varenicline also includes a quantity limit (QL) entry (e.g., QL (2 per 1 day) or packed dose QL).

No step-therapy sequence provided in this excerpt; follow Requirements Limits and ACA/SC designation for benefit application.

Step Therapy & Sequencing Rules

Step therapy requirement
Documentation of trial/failure of specified alternatives is required before coverage at preferred cost-sharing (Step Therapy/ST).

Managed-entry flags present
Presence of flags such as PA, ONC, TD or S in formulary entries suggests managed entry pathways (e.g., oncology program, therapy-directed programs, specialty handling) and possible step or program edits.

Explicit step sequences
No explicit step-therapy sequences are provided in the listed migraine/adjunctive entries; only Requirements/Limits flags (e.g., PA, QL) are shown for individual products.

Tiering and implied sequencing
Tier assignments (Tier 1–4) indicate preferred sequencing; products assigned to higher tiers may imply requirement to try lower-tier agents first prior to coverage at preferred tier levels.

FETZIMA / FANAPT flags
FETZIMA and FANAPT formulations are listed with PA (and for FETZIMA, QL), indicating prior authorization and quantity-limit controls that imply utilization management or step/PA requirements before coverage.

TRINTELLIX / zolpidem
TRINTELLIX and some hypnotic formulations are annotated with 'ST' (step therapy) and QL, indicating step therapy must be met (trial/failure of alternatives) prior to coverage.

DOACs / anticoagulant dosing packs
Selected DOAC products and dosing start packs (ELIQUIS, XARELTO) include QL entries and some injectable anticoagulant formulations show S/PA flags; these quantity limits and specialty flags indicate utilization edits and possible PA prior to coverage.

Explicit sequences in fragment
No explicit step-therapy sequences are listed in this fragment; entries display tier and administrative flags (PA, QL, S) without step-algorithm detail.

ISTURISA / GALAFOLD 'S' annotation
ISTURISA and GALAFOLD are annotated with 'S' (step), indicating a step therapy requirement (trial of specified alternatives) applies before coverage of these agents.

Specialty biologics / immunology agents
Multiple specialty biologics and immunology agents (e.g., PEGASYS, CIMZIA, ADALIMUMAB variants, ENBREL, ORENCIA) are labeled with PA and S (and often QL), indicating specialty pathways and step/edit requirements and prior authorization before coverage.

Products with 'S' and PA
Entries that show 'S' alongside PA (for example PALFORZIA levels, certain biologics and osteoporosis agents) denote that step-edit requirements or specialty program steps must be followed when present.

Oral/systemic agents designated PA
Several oral/systemic agents (e.g., BIJUVA, DUAVEE, MYFEMBREE, ORIAHNN, OSPHENA) are designated 'PA' in the Requirements/Limits column, indicating prior authorization is required before coverage.

Quantity Limits (Selected Examples)

inv-153: nystatin oral suspension — QL 480

nystatin oral suspensionQuantity limit recorded: 480 (QL 480 per 30 days)

Table sourceListed under antifungal agents in abbreviations/table with 'Requirements Limits = QL (480 per 30 days)'

Dispensing implicationClaims beyond 480 units/30 days subject to review/documentation

inv-154: nystatin oral suspension duplicate entry — QL 480

nystatin oral suspension (duplicate)Quantity limit reiterated: 480 per 30 days

NoteSame QL appears multiple times in table (confirmation of limit)

ActionPrescribers should note 30‑day cap when authorizing refills

inv-155: oseltamivir 30 mg — QL 20

oseltamivir 30 mg capsulesQuantity limit: QL (20 per 30 days)

ContextOseltamivir suspension and other strengths have separate QLs (e.g., QL 180 per 30 days for suspension)

ImplicationDispensing beyond QL requires medical necessity documentation

inv-156: oseltamivir 45/75 mg — QL 10

oseltamivir 45/75 mg capsulesQuantity limit: QL (10 per 30 days)

Table noteDifferent strengths have different QLs recorded in the antiviral section

Provider noteConfirm strength when assessing QL and overrides

inv-157: oseltamivir suspension — QL 180

oseltamivir oral suspension for reconstitutionQuantity limit: QL (180 per 30 days)

Strength/contextSuspension entry lists QL (180 per 30 days) in antiviral abbreviations

ImplicationAppropriate for pediatric dosing; excess requires review

inv-158: PAXLOVID dose pack — QL 6

PAXLOVID dose packQuantity limit: QL (6 per 1 day) — listed as QL per 1 day in dose‑pack entry

SourcePAXLOVID ORAL TABLETS, DOSE PACK entries show QL (6 per 1 day)

Clinical noteDose‑pack QL enforces single‑episode dispensing controls

inv-159: linezolid 600 mg — QL 2

linezolid oral tablet 600 mgQuantity limit: QL (2 per 1 day)

Linezolid suspensionLinezolid oral suspension for reconstitution is listed with PA in table; tablet has QL (2 per 1 day)

ImplicationDaily QL restricts chronic high‑dose use without justification

inv-160: YEZTUGO 300 mg — QL 4

YEZTUGO oral tablet 300 mgQuantity limit: QL (4 per 30 days)

Table placementListed among antiviral/anti‑infective entries with QL 4 per 30 days

Dispensing noteMonthly cap reflected in formulary QL field

inv-161: ALINIA suspension — QL 180

ALINIA (nitazoxanide) oral suspensionQuantity limit: QL (180 per 30 days)

EntryALINIA oral suspension listed with QL 180 per 30 days in antiviral/antiinfective section

Provider noteLarge 30‑day QL appropriate for multi‑dose pediatric suspension courses

inv-162: tetracycline capsule — QL 56; inv-163: fosfomycin packet — QL 3

Tetracycline oral capsuleQuantity limit: QL (56 per 30 days)

Fosfomycin packetQuantity limit: QL (3 per 30 days) — fosfomycin tromethamine 3 g packet

ContextThese QLs are listed in the urinary/anti‑infective section for outpatient use

inv-164: IBRANCE / LYNPARZA daily-equivalent QLs example

Oncology daily-equivalent QLsIBRANCE listed with QL (0.75 per 1 day); LYNPARZA and others have daily‑equivalent QLs in oncology entries

PurposeConverts pack strength/regimen into per‑day dispensing limits (used for oral oncolytics)

ActionOverrides require oncology documentation and PA where applicable

inv-165: ROZLYTREK 100 mg — QL 1

ROZLYTREK 100 mg capsuleQuantity limit: QL (1 per 1 day)

ROZLYTREK 200 mg capsuleQuantity limit: QL (3 per 1 day) — separate strength-specific QL

Table contextROZLYTREK strengths each list strength‑specific QLs in adjunctive oncology section

inv-166: ROZLYTREK 200 mg — QL 3

ROZLYTREK 200 mg capsuleQuantity limit: QL (3 per 1 day)

Strength noteHigher strength shows higher per‑day QL as listed in oncology adjunctive agents

Provider actionPA/ONC flags apply in addition to QL for these agents

inv-167: VERZENIO various strengths — QL 2; inv-168: XTANDI 40 mg — QL 4

VERZENIO (abemaciclib)Quantity limit: QL (2 per 1 day) — applies across listed strengths

XTANDI 40 mgQuantity limit: QL (4 per 1 day) — XTANDI entries show QL by strength

Oncology controlsMany oncology agents include PA; ONC; TD; S flags in addition to QL

inv-169: AJOVY 225 mg — QL 0.054; inv-170: EMGALITY 120 mg — QL 0.036

AJOVY autoinjector 225 mgQuantity limit: QL (0.054 per 1 day)

EMGALITY pen 120 mgQuantity limit: QL (0.036 per 1 day)

Daily-equivalent noteMigraine biologic pens use small per‑day QL fractions to control dispensing frequency

inv-171: NURTEC ODT 75 mg — QL 0.267; inv-172/173: sumatriptan QLs

NURTEC ODT 75 mgQuantity limit: QL (0.267 per 1 day)

Sumatriptan (oral)Quantity limit: QL (0.429 per 1 day) for oral tablets

Sumatriptan subcutaneousQuantity limit: QL (0.167 per 1 day) for subcutaneous preparations

Specialty Pharmacy & Infusion/Administration Notes

Note

Background & Scope

Background: Specialty medicines are high‑cost therapies often used for chronic or complex diseases; they frequently require additional clinical management and are not routinely stocked at retail pharmacies. As noted in the formulary, these products commonly require specialty pharmacy dispensing and may be covered under a different benefit with plan‑specific rules. The HealthPartners formulary is governed and reviewed on a recurring schedule (see policy front matter) and uses tiering and requirement flags to manage access to these high‑cost medicines.

HealthPartners 2026 Formulary — Coverage Criteria (Pharmacy & Specialty Drugs)

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Coverage & Utilization Management

Drug Entries & Codes

Prior Authorization, Step Therapy & Documentation

Initial Coverage & Prior Authorization Examples

Step Therapy & Sequencing Rules

Quantity Limits (Selected Examples)

Specialty Pharmacy & Infusion/Administration Notes

Key Symbols & Terms

Background & Scope