HealthPartners Formulary — Drug List and Coverage Rules (Pharmacy & Specialty Drugs)
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Governs the HealthPartners covered drug list (formulary), tiering, and common utilization management programs (prior authorization, step therapy, age limits, quantity limits, specialty pharmacy) for HealthPartners members and providers.
No material clinical or coverage changes in this revision.
Coverage criteria and formulary rules
General coverage rule
Coverage depends on meeting formulary program rules.
If requirements are not met, prior authorization or other approval is required and the claim may be denied
Per-product formulary coverage and limits
Coverage and utilization management are applied per product line as shown on the formulary table.
Follow the per-line Requirements / Limits when adjudicating coverage or when submitting prior authorization requests
General coverage conditions for listed products
Coverage and utilization controls are applied per listed product when ALL of the following listed requirements are met on the claim or prior authorization.
Many extended‑release opioid strengths and other specialty products explicitly require PA and have specific QL values; denial may occur if these controls are not met
Formulary coverage summaries
Coverage stances vary by product; many items are covered subject to the listed requirement flags (PA, QL, ENH, AL, NP, S, TD, ST).
Use per-line flags to determine exact coverage pathway; specialty and enhanced review flags may require additional documentation
Over-the-counter (OTC) drugs are generally not covered unless otherwise noted. This means OTC products will be excluded from coverage unless a specific formulary entry or plan exception indicates otherwise; requests for OTC products should be checked against the drug list for any listed coverage exceptions or flags prior to adjudication.
This excerpt does not contain a separate narrative list of explicit textual exclusions beyond the per-line table entries. Certain rows in the formulary table are annotated with the flag NP (a requirement/limit abbreviation shown in the table); the table header and definitions (located at the start of the full drug list) explain the precise meaning of those abbreviations.
Some product entries are marked NP in the Requirements / Limits column. Items flagged NP are treated as non-preferred and may be subject to additional utilization controls (for example, higher member cost-share, requirement to try preferred alternatives, or denial where a preferred alternative is available). The excerpted table uses NP on select combinations (see, for example, diclofenac-misoprostol entries).
Claims for OTC drugs that do not have a specific coverage exception noted on the formulary may be denied as not covered. Verify whether a listed OTC product has an explicit plan exception or an Affordable Care Act/preventive designation before submitting a claim; absent such an exception, coverage should not be assumed.
Several formulary rows include the NP flag in the Requirements / Limits column; the full table header (not included in this excerpt) defines the abbreviation and its operational implications. Because the excerpt does not reproduce the header definition, refer to the table start for the exact policy meaning of NP when applying coverage rules or adjudicating claims.
Products specifically flagged NP in the formulary (for example, the diclofenac–misoprostol oral tablet shown with PA; NP) are considered non-preferred and may be denied, require substitution with a preferred alternative, or have other plan-imposed restrictions. Follow the plan’s utilization controls for non-preferred items when processing prior authorization requests or claims.
Formulary coding, requirement codes, and examples
| ANCOBON ORAL CAPSULE 250 MG, 500 MG | Drug Tier = NF; Requirements / Limits = PA |
| clotrimazole mucous membrane troche 10 mg | Drug Tier = 2 |
| CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG | Drug Tier = 3; Requirements / Limits = PA; NP |
| fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg | Drug Tier = 1 |
| flucytosine oral capsule 250 mg, 500 mg | Drug Tier = 2; Requirements / Limits = PA |
| nystatin oral suspension 100,000 unit/ml | Drug Tier = 2; Requirements / Limits = QL (480 Per fill) |
| VIVJOA ORAL CAPSULE 150 MG | Drug Tier = NF; Requirements / Limits = PA; QL (18 per 84 days) |
| voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) | Drug Tier = 2; Requirements / Limits = PA |
| BEYFORTUS INTRAMUSCULAR SYRINGE 100 MG/ML, 50 MG/0.5 ML | Drug Tier = 3; Requirements / Limits = ACA |
| Biktarvy, Genvoya, Harvoni, Epclusa and other listed branded antivirals | Various tiers and limits noted (PA, S, NF) as listed in the drug table |
| QL (1 per 1 day) | Quantity limit example shown for products such as GILOTRIF, ICLUSIG |
| QL (21 per 28 days) | Quantity limit example for IBRANCE and KISQALI (21 per 28 days) |
| QL (3 per 1 day) | Quantity limit example for HERNEXEOS/IBTROZI |
| PA | Prior authorization requirement |
| ONC | Oncology designation |
| TD | Therapy/diagnostic designation (documented in list) |
| S | Site or specialty restriction |
Provider requirements, prior authorization, step therapy, and denial triggers
Prior authorization required
Prior authorization (PA) is required for many medicines on the formulary; prescribers must obtain PA to confirm the medication meets HealthPartners prior authorization criteria before coverage will be provided.
- PA appears in the Requirements / Limits column for numerous products across the formulary and must be obtained prior to coverage.
Prior authorization required for select antiviral agents
Select antiviral and hepatitis agents are designated PA (and often S); prescribers must submit prior authorization requests for products such as LEDIPASVIR‑SOFOSBUVIR (Harvoni), SOFOSBUVIR‑VELPATASVIR (Epclusa), GENVOYA, and MAVYRET per HealthPartners processes.
- Antiviral entries list Requirements / Limits = PA; S for multiple branded hepatitis/antiviral products.
- Obtain PA to confirm the medication meets plan criteria before coverage.
Prior authorization required
Many listed drugs across therapeutic classes require prior authorization; prescribers must submit PA requests following HealthPartners’ prior authorization procedures when 'PA' appears in the Requirements / Limits field.
- 'PA' is shown next to numerous products in the formulary table indicating PA must be obtained prior to coverage.
Prior authorization required
Oncology and other specialty agents frequently carry a PA requirement (often combined with ONC and S flags); providers must submit prior authorization per payer process before these specialty medications will be covered.
- Many oncology entries show 'PA; ONC; S' indicating PA plus oncology and specialty handling is required.
- Specialty oncology medicines are typically dispensed via specialty pharmacy (see site‑of‑care rules).
PA required for listed drugs
Multiple specific drugs in the excerpt are labeled with 'Requirements / Limits = PA'; prescribers must obtain prior authorization for those products before coverage.
- Examples in the table show PA flags on many individual product rows; absence of approved PA may prevent coverage.
Prior authorization required for many listed agents
Several neurology and seizure‑disorder agents (e.g., EPIDIOLEX, FYCOMPA, KEPPRA entries) are flagged with PA; prescribers must submit prior authorization requests for these products when PA is indicated.
- EPIDIOLEX entry shows 'PA; S; QL (20 per 1 day)'.
- KEPPRA and FYCOMPA entries are listed with Requirements / Limits = PA.
PA required for listed products
Many Neurology & Psychiatry products in the formulary are designated 'PA' in the Requirements / Limits column; prescribers must obtain prior authorization per plan procedures for these medications.
- Multiple anticonvulsants and CNS agents in the table include PA flags requiring authorization before coverage.
Prior authorization required
Where the Requirements / Limits column shows 'PA', prescribers must submit prior authorization requests to obtain coverage; this applies across multiple therapeutic categories shown in the formulary.
- The table repeatedly annotates products with 'PA' indicating prior authorization is required prior to dispensing and reimbursement.
Prior authorization required for many products
Numerous opioid and certain NSAID products are listed with 'PA' and QL; prescribers must obtain prior authorization for many extended‑release opioid formulations and other flagged analgesics.
- Hydrocodone ER entries show 'PA; QL' for different strengths; XTAMPZA ER lists 'PA; QL (2 per 1 day)'.
- Failure to obtain PA may result in claim denial for these products.
Prior authorization required for many listed products
Throughout the formulary excerpt many products are designated 'PA' in Requirements / Limits; prescribers must secure prior authorization for those items before coverage will be approved.
- Examples of PA‑designated products appear across chunks 162–181 and elsewhere in the drug table.
Prior authorization required for PA‑designated drugs
Prescriptions for products marked 'PA' require prior authorization before coverage; obtain and document the required PA to avoid claim denial.
- The policy states PA is required before coverage for PA‑designated items in the Requirements / Limits column.
Prior Authorization required for many CNS agents
Numerous CNS agents (anticonvulsants, psychotropic drugs) include 'PA' flags; prescribers must obtain prior authorization per plan procedure for these central nervous system medications.
- Entries in the Neurology & Psychiatry sections include PA, QL, and other flags that require authorization to be obtained prior to coverage.
Prior authorization required
Many specialty products (biologics, factor concentrates, high‑cost injectables) are listed with 'PA' and 'S'; providers must submit prior authorization and follow specialty workflows (including specialty pharmacy/site‑of‑care rules).
- Entries for factor and specialty products show 'PA; S' indicating PA plus specialty dispensing requirements.
- Specialty medicines must be filled at a specialty pharmacy per the formulary notes.
Prior authorization required for many specialty products
Prior authorization is required for many specialty and high‑cost products listed with 'PA' in Requirements / Limits; providers must submit PA requests per HealthPartners processes for these items.
- Specialty entries (e.g., ARIXTRA, factor products) include PA and often QL; obtain PA before dispensing to ensure coverage.
Step therapy requirement
Some medicines require step therapy: the prescriber must document prior trial and failure (or intolerance) of the required preferred agent(s) before requesting coverage for the non‑preferred product.
- Step therapy is applied where products are marked 'S' or 'ST' in the product listing; if step requirements are not met, approval must be requested.
Step therapy indicators
Products marked with 'S' in the formulary (examples include GENVOYA, HARVONI, MAVYRET) indicate a step therapy or sequencing requirement; follow the step indication and submit documentation of prior trials when requesting authorization.
- The antiviral entries show 'PA; S' or 'PA; S' flags indicating step sequencing alongside PA.
Step therapy indicated
Agents with an 'S' flag in Requirements / Limits are subject to step therapy; prescribers must follow the step requirement as indicated and provide documentation of prior step failures when requesting authorization.
- Several neurologic and specialty products are annotated with 'S' signaling a step edit that must be met for coverage.
Step/site restrictions
Some items display 'S' indicating site or specialty restrictions as well as step requirements; prescribers must follow step therapy rules and site‑of‑care/specialty dispensing instructions where indicated.
- Oncology and specialty products commonly show 'S' meaning specialty handling or site restrictions in addition to PA.
Step therapy not specified
The formulary shows 'S' and other step flags but does not include the explicit step‑by‑step algorithms in this excerpt; specific step therapy logic must be confirmed via the payer's step therapy procedures when submitting requests.
- Table flags indicate step edits are present but the excerpt lacks detailed sequencing rules; contact HealthPartners or use the PA submission portal for exact step criteria.
Step therapy not specified
Many entries include administrative flags (PA, NP, S, QL, ST) without detailed step sequences in this excerpt; the document shows flags but not the explicit step‑therapy logic or required prior agents.
- When 'S' or 'ST' appears, step therapy applies, but the excerpt does not provide the full step algorithm—use payer resources for detailed requirements.
Step edits present
Some products in the table are explicitly flagged with step edits (S) such as vigabatrin, GOCOVRI, and AUSTEDO entries; when 'S' is present, follow the step edit and supply documentation of prior therapy as part of the authorization.
- Vigabatrin is listed with 'PA; S'; AUSTEDO shows 'PA; S; QL (1 per 1 day)' indicating a step edit and PA requirement.
Step therapy requirement
When a product's Requirements / Limits include 'S' or 'step', step therapy must be followed; prior step failures or intolerances should be documented in the PA request to support approval.
- The policy states that documentation of prior step failures is required when 'S' is listed to authorize the requested product.
Documentation for quantity limit overrides
Many formulary entries include QL values; requests above the quantity limit will be reviewed for medical necessity and must include diagnosis, alternatives tried, prior use within limits, and clinical rationale to support an override.
- The QL section instructs that requests above quantity limits require medical necessity review including diagnosis and alternatives tried.
Prior authorization documentation
Entries flagged 'PA' require prior authorization documentation to be submitted with the request (for example KALETRA and RETROVIR entries are listed with PA); include clinical justification when submitting PA.
- The formulary shows KALETRA and RETROVIR with Requirements / Limits = PA; submission of PA documentation is required for coverage.
Oncology documentation signals
Oncology entries frequently include 'PA; ONC' and may require oncology‑specific supporting documentation; when ONC appears, include appropriate oncology documentation with the authorization request.
- Many oncology agents are labeled PA; ONC; S indicating oncology benefit handling and that oncology documentation will be needed.
Supporting documentation
Formulary product rows include requirement flags (PA, ONC, S, TD, QL); providers must follow these flags and submit documentation that supports the listed requirements with authorization requests.
- Use the Requirements / Limits flags shown on the product row to determine which documentation and reviews are needed for authorization.
Required claim details
Pharmacy claims must include product, strength, and quantity consistent with the listed quantity limits (QL) to avoid overrides or claim denials; ensure claim details match the formulary QL for the product.
- Claims inconsistent with listed QL or missing PA may be denied at adjudication.
Prior authorization denial triggers
Requests for drugs that require prior authorization, exceed quantity limits, or are marked NP/ENH/S may be denied if the required authorization or documentation is not obtained and submitted.
- The policy notes coverage may be denied if PA criteria are not met, or if QL is exceeded without documentation.
Documentation to support PA and QL
For products with Requirements / Limits = PA; S; QL, include clinical justification, step‑therapy history, dosing, and quantity rationale in the prior authorization request to support approval.
- The documentation guidance states prescriptions with PA; S; QL should include clinical justification and step history where 'S' is present.
Background and policy context
Specialty medicines are typically used to treat chronic or complex conditions, are often high-cost, and require additional management and dispensing controls. These products commonly require prior authorization, may be dispensed through a specialty pharmacy, and can be subject to quantity limits, age limits, step edits, or oncology-specific workflows as indicated on the formulary.
Definitions and abbreviations used in the formulary
Step therapy rules and products flagged for step edits
| Overview | Guidance / Policy |
|---|---|
| Step therapy (ST) — general definition | When a product on the HealthPartners drug list is designated for step therapy (ST or S), members must trial and fail the required preferred agent(s) before the non-preferred product will be covered at the applicable formulary tier. If step requirements are not met, prior authorization (PA) or approval is required for coverage. |
| How step therapy is indicated on the drug list | The formulary flags ST or S in the Requirements / Limits column to indicate a step/sequence requirement; see the drug list entry for specific indications. Where S/ST appears, follow the payer step-therapy pathway or submit PA documenting prior trials and reasons for failure/intolerance. |
| Effect of not meeting step requirements | Coverage may be denied or require approval if step therapy requirements are not met — prescribers should submit clinical justification and prior-treatment history to request an exception. |
| Antiviral agent(s) | Formulary flags / Note |
|---|---|
| GENVOYA (oral tablet) | Listed on the formulary; antiviral entries include S in some product lines indicating step/sequence requirements (see drug table). |
| HARVONI (oral pellets / tablets) | Requirements / Limits = PA; S shown for specific HARVONI presentations indicating step therapy or sequencing applies for certain forms/strengths. |
| MAVYRET (oral pellets / tablets) | Listed with Requirements / Limits = PA; S for some MAVYRET presentations — S flag implies step therapy or sequencing requirement prior to coverage. |
| SOFOSBUVIR-VELPATASVIR (SOVALDI / EPCLUSA family) | Several hepatitis antivirals (LEDIPASVIR-SOFOSBUVIR, SOFOSBUVIR-VELPATASVIR) are shown with PA and S flags indicating step/sequence requirements per formulary. |
| Statement | Implication |
|---|---|
| Products marked with 'S' flag | An 'S' shown in the Requirements / Limits column indicates a step therapy or specialty sequencing requirement applies for that product; prior trial of preferred therapy is expected before coverage. Specific step sequences or the required first-line agent(s) are not detailed in this excerpt — see plan drug list or prior authorization criteria for the exact step algorithm. |
| Action for prescribers | When S is listed, prescribers should document prior trials and failures or request prior authorization with supporting clinical information to obtain coverage for the requested product. |
| Flag(s) | Meaning / Use |
|---|---|
| S (Specialty / Step) or TD (Trial Drug / Tumor-directed) | Entries tagged 'S' or 'TD' indicate additional utilization controls — e.g., specialty designation, step edits, or tumor-directed restrictions — and require following plan procedures (PA, documentation, specialty pharmacy) as listed on the drug table. |
| Examples | Multiple oncology and specialty oral agents show combinations of PA; ONC; TD; S indicating both clinical and site-of-care controls apply to coverage and may include step/sequence expectations. |
| Observation | Consequence |
|---|---|
| No explicit step sequences in excerpt | The provided formulary segments predominantly display per-product flags (PA, QL, S, NP, ENH) but do not include multi-step algorithms or ordered step lists within this excerpt — step-therapy logic must be obtained from the full formulary documentation or PA criteria where specified. |
| Operational note | Clinicians must refer to the detailed prior authorization/step-therapy criteria or contact the plan for required prior agent(s) and documented failure criteria when S/ST is shown. |
| Product examples | Formulary flag |
|---|---|
| Vigabatrin (vigabatrin oral powder / tablet) — neurology entry | Requirements / Limits = PA; S (step edit indicated for vigabatrin) |
| GOCOVRI / AUSTEDO entries (tardive dyskinesia therapies) | Certain titration packs and formulations list PA; S; QL — S indicates step or specialty edit applies to these products. |
| Policy statement | Required provider action |
|---|---|
| Step therapy must be followed when 'S' is listed | When a product's Requirements / Limits include 'S' or 'ST', step therapy must be followed. Providers should document prior trials and reasons for discontinuation or intolerance when submitting a PA or exception request. |
| Documentation expectations | PA requests for S-designated products should include prior-treatment history showing trials of preferred agents and clinical rationale for the requested non-preferred therapy. |
| Observation | Implication |
|---|---|
| Many products controlled via PA/QL rather than explicit ST sequences | Across the extract a large number of entries are managed by prior authorization and quantity limits. Explicit multi-step sequences are often not shown in the table excerpt; follow PA/QL rules or consult full step-therapy criteria for ST details. |
| Product types | Formulary implication |
|---|---|
| Long-acting injectables and branded oral agents (examples: injectable antipsychotics, depot formulations) | Some long-acting injectable and branded oral agents are listed with NP or PA/NP designations; this commonly implies a requirement to trial preferred agents (or alternate formulations) before coverage of the non-preferred product, consistent with step/coverage preference policies. |
| Product | Formulary flags |
|---|---|
| TRINTELLIX (vortioxetine) oral tablet | Requirements / Limits = ST; NP; QL (1 per 1 day) — listing indicates step therapy (ST) may apply for TRINTELLIX. |
| Product | Formulary requirement |
|---|---|
| Zolpidem extended-release (multiphase) formulations | Requirements / Limits = ST; QL (1 per 1 day) — zolpidem extended-release is specifically listed with ST (step therapy) and a daily quantity limit of 1 dose. |
| Drug group | Formulary flags / Note |
|---|---|
| Oral anticoagulants and antiplatelet agents (examples: ELIQUIS, ARIXTRA, BRILINTA) | Some anticoagulant/antiplatelet listings are marked 'ENH' or 'PREV' (and include QL); ENH/PREV flags indicate enhanced review or preventive-program handling which can function like step/enhanced review before coverage. Follow the specific Requirements / Limits for each product. |
Quantity limits by product (selected examples)
Specialty pharmacy and site restrictions
Specialty pharmacy requirement
Specialty medicines (S flag) must be filled at a specialty pharmacy and often have PA and site‑of‑care requirements; verify specialty pharmacy fulfillment and any PA/site restrictions prior to dispensing.
- Chunk 2 explains specialty medicines must be filled at a specialty pharmacy; many specialty products in the table include 'S' flags.
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