CurrentHealthPartnersPolicy N/A
2026 Formulary (Drug List) — Pharmacy Coverage Criteria
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Governs the HealthPartners pharmacy drug list (formulary) effective January 1, 2026; informs members and providers about covered medicines, tiers, specialty designations, limits, and prior authorization/step-therapy programs.
Policy Summary
PayerHealthPartners
Policy2026 Formulary (Drug List) — Pharmacy Coverage Criteria
Policy CodePolicy N/A
Change TypeAnnual formulary publication (no material changes)
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization for any product listed with 'PA' before dispensing to ensure coverage.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
QuarterlyFormulary review frequency
Tiers 1–7Drug tiers
multiplePrior Authorization (PA)
severalQuantity Limits (QL)
Specialty pharmacySpecialty routing
Coverage Criteria
Quantity Limit Review Criteria
Coverage decisions and overrides
Quantity limit override: Requests above the quantity limit will be reviewed for medical necessity and must include evaluation of the diagnosis, alternatives previously tried, prior use of the requested product within the quantity limit, and evidence of efficacy and safety at the quantity requested.QL exceeded
Supports prior authorization review
Step Therapy Coverage
Step therapy coverage logic
Step therapy requirement: A medicine with step therapy will be covered if the member has already tried the required prior medicine(s); if prior steps have not been completed, prior approval from HealthPartners is required before the medicine will be covered at the lower cost-share.prior trial of specified agents
Approval needed if prior steps not met
Formulary administrative criteria
Coverage and administrative requirements as listed for products in this section
Formulary entries: Products are listed with a Drug Tier and 'Requirements Limits' flags (examples shown: ACA, PA, QL, S, ONC, TD). Coverage for each product follows the listed requirement: ACA indicates mandated/ACA-related coverage, PA indicates prior authorization is required before coverage, QL indicates a numeric quantity limit, and S/ONC/TD indicate specialty/program routing or trial distribution requirements.
Administrative flags reflect coverage pathways; no clinical medical necessity criteria are provided in these chunks.
Coverage stance by formulary entry
Formulary coverage and requirements as listed per product entry
Entry-level: Each product row indicates Drug Tier and Requirements Limits; coverage is subject to those stated requirements. Examples: contraceptives and related devices marked 'ACA' are covered under ACA provisions; products marked 'PA' require prior authorization before coverage; products with 'QL' are limited to the stated quantity (e.g., ANNOVERA QL 1 per 273 days; emergency oral levonorgestrel QL 3 per 30 days; condoms QL 60 per 30 days).
Reflects product-level coverage stance as listed in the formulary table.
Failure to obtain required Prior Authorization (PA) may result in a prescription not being covered under the HealthPartners pharmacy benefit. Drugs that are flagged with PA in the formulary must have prior approval from the payer before coverage will be provided.
Within the provided formulary excerpts there are no explicit medical exclusions stated. Product rows show administrative flags such as PA, QL and ACA, but the text in these chunks does not list medicines as specifically excluded for medical reasons.
The excerpted lines do not present explicit exclusion statements. Entries list device and product coverage annotations (for example ACA, QL, PA) but do not identify any products as expressly excluded from coverage for clinical or medical-necessity reasons.
This section only shows product-level requirement and limit codes (e.g., PA, QL) for ophthalmic and related entries. There are no explicit exclusion rules stated in the provided lines — only the per-product requirement/limit annotations are shown.
Within the supplied extract there are no statements identifying items as 'not medically necessary'. The lines include requirement flags and tiering but do not contain explicit 'not medically necessary' determinations.
Formulary Listings and Coding Examples
Formulary drug listings and limits (examples)mixedCovered
| NOXAFIL ORAL SUSP,DELAYED RELEASE FOR RECON 300 MG | listed with Drug Tier = 3, Requirements Limits = PA |
| nystatin oral suspension 100,000 unit/ml | listed with Drug Tier = 3, Requirements Limits = QL (480 per 30 days) |
| posaconazole oral suspension 200 mg/5 ml (40 mg/ml) | listed with Drug Tier = 3, Requirements Limits = PA |
| voriconazole oral tablet 200 mg, 50 mg | listed with Drug Tier = 3, Requirements Limits = PA |
| abacavir oral tablet 300 mg | listed with Drug Tier = 3, Requirements Limits = . |
| acyclovir oral tablet 400 mg, 800 mg | listed with Drug Tier = 3, Requirements Limits = . |
Sample formulary entriesmixed
| nystatin oral suspension 100,000 unit/ml | Listed with Drug Tier = 3; QL (480 per 30 days) |
| posaconazole oral suspension 200 mg/5 ml (40 mg/ml) | Drug Tier = 3; Requirements Limits = PA |
| voriconazole oral tablet 200 mg, 50 mg | Drug Tier = 3; Requirements Limits = PA |
| abacavir oral solution 20 mg/ml | Drug Tier = 3 |
| BIKTARVY ORAL TABLET 30-120-15 MG | Drug Tier = 3 |
| EPCLUSA ORAL TABLET 200-50 MG | Requirements Limits = PA; S |
| HARVONI ORAL TABLET 45-200 MG | Requirements Limits = PA; S |
| LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG | Drug Tier = 6; Requirements Limits = PA; S |
| MAVYRET ORAL TABLET 100-40 MG | Drug Tier = 6; Requirements Limits = PA; S |
Antiviral dose packs and QLsmixedCovered
| oseltamivir oral capsule 30 mg | Drug Tier = 3; QL (20 per 30 days) |
| oseltamivir oral capsule 45 mg, 75 mg | Drug Tier = 3; QL (10 per 30 days) |
| PAXLOVID ORAL TABLETS, DOSE PACK 150 | Drug Tier = 3; QL (4 per 1 day) |
| PAXLOVID ORAL TABLETS, DOSE PACK 300 MG | Drug Tier = 3; QL (6 per 1 day) |
Misc antiinfectives with PA/QLmixed
| ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML | Drug Tier = 4; Requirements Limits = PA; QL (180 per 30 days) |
| linezolid oral tablet 600 mg | Drug Tier = 3; Requirements Limits = QL (2 per 1 day) |
| XIFAXAN ORAL TABLET 200 MG, 550 MG | Drug Tier = 3; Requirements Limits = PA |
Antibiotics (selected entries)mixed
| amoxicillin oral suspension for reconstitution 125 mg/5 ml | Drug Tier = 3 |
| amoxicillin oral tablet 500 mg | Drug Tier = 3 |
| amoxicillin-pot clavulanate oral tablet 250-125 mg | Drug Tier = 3 |
| ampicillin oral capsule 500 mg | Drug Tier = 3 |
| dicloxacillin oral capsule 250 mg | Drug Tier = 3 |
Fluoroquinolones & Sulfonamidesmixed
| ciprofloxacin hcl oral tablet 250 mg | Drug Tier = 3 |
| levofloxacin oral tablet 250 mg | Drug Tier = 3 |
| moxifloxacin oral tablet 400 mg | Drug Tier = 3 |
| sulfadiazine oral tablet 500 mg | Drug Tier = 4; Requirements Limits = PA |
| sulfamethoxazole-trimethoprim oral tablet 400-80 mg | Drug Tier = 3 |
Antineoplastic & immunosuppressant agentsmixed
| abiraterone oral tablet 250 mg | Requirements Limits = PA; ONC; TD; S |
| anastrozole oral tablet | Drug Tier = 7; Requirements Limits = ONC |
| capecitabine oral tablet 150 mg | Requirements Limits = ONC; S |
| dasatinib oral tablet 100 mg | Requirements Limits = PA; ONC; TD; S |
| everolimus (antineoplastic) oral tablet 10 mg | Requirements Limits = PA; ONC; TD; S; QL (1 per 1 day) |
Targeted cancer therapiesmixed
| ROZLYTREK ORAL CAPSULE 100 MG | Requirements Limits = PA; ONC; TD; S; QL |
| TAGRISSO ORAL TABLET 40 MG | Drug Tier = 7; Requirements Limits = PA; ONC; TD; S; QL (1 per 1 day) |
| TAFINLAR ORAL CAPSULE 50 MG | Requirements Limits = PA; ONC; S |
Product entries (no billing codes in this excerpt)mixed
| N/A | No explicit CPT/HCPCS/ICD-10/NDC codes present in these chunks; only product names, formulations, and tiers are listed. |
Formulary products (examples)NDC|product
| XELJANZ XR 11 MG, 22 MG | XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR |
Selected products with PA notedproduct
| BIJUVA | BIJUVA ORAL CAPSULE 0.5-100 MG, 1-100 MG |
| DUAVEE | DUAVEE ORAL TABLET 0.45-20 MG |
| MYFEMBREE | MYFEMBREE ORAL TABLET 40-1-0.5 MG |
| ORIAHNN | ORIAHNN ORAL CAPSULE, SEQUENTIAL 300-1-0.5MG(AM) /300 MG(PM) |
| OSPHENA | OSPHENA ORAL TABLET 60 MG |
Contraceptive devices and patchesproductCovered
| ANNOVERA | ANNOVERA VAGINAL RING 0.15-0.013 MG/24 HOUR |
| TWIRLA | TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24 HR |
| VCF | VCF CONTRACEPTIVE FILM VAGINAL FILM 28 % |
Oral contraceptives — tiers and limitsmixedCovered
| QL (3 per 30 days) | Quantity limit for certain oral contraceptives (3 per 30 days) |
| Drug Tier = 3 | Tier assignment for listed oral contraceptives |
| Requirements Limits = ACA | Coverage requirement/limit code (ACA) |
Ophthalmic products — tiers and requirement codesmixedCovered
| PA | Prior authorization required (appears for several ophthalmic agents) |
| QL (5 per 30 days) | Quantity limit for CYSTADROPS |
| QL (15 per 30 days) | Quantity limit for CYSTARAN |
| S | Specialty or site restriction |
| Drug Tier = 4 | Tier assignment for some ophthalmic products (e.g., LEVOFLOXACIN 0.5% listed as Tier 4) |
inv-25: nystatin oral suspension limit — 480 per 30 days
Productnystatin oral suspension 100,000 unit/ml — QL 480 per 30 days
Limit value480 per 30 days
Formulary tier/contextListed as Drug Tier = 3 with Requirements Limits = QL
inv-26: Quantity limits examples
Nystatin suspensionQL 480 per 30 days
Oseltamivir oral capsule 30 mgQL 20 per 30 days
ALINIA oral suspension 100 mg/5 mLQL 180 per 30 days
inv-27: Quantity limits examples
Tetracycline oral capsule 250 mgQL 56 per 30 days
Fosfomycin tromethamine oral packet 3 gramQL 3 per 30 days
Formulary contextBoth entries show explicit QL values in the Requirements Limits column
inv-28: Example Quantity Limits — includes per day and per 30 day fractions
Per-day fractional QLs (examples)QL values expressed as fractions per day (e.g., QL 1 per 1 day; QL 2 per 1 day)
Per-30-day QLs (example)QL entries also shown as 'per 30 days' in the table
Usage noteFormulary displays QL using both per-day fractions and per-30-day totals depending on product presentation
inv-29: Quantity Limits examples — multiple fractional/day examples
Fractional/day examplesQLs expressed as fractional per day values (e.g., 0.4 per 1 day; 0.429 per 1 day; 0.167 per 1 day)
Higher per-day QLsExamples include QL 4 per 1 day and QL 2 per 1 day for certain products
Extended-period examplesSome QLs reference multi-day denominators (e.g., 28 per 273 days) as shown in the table
inv-30: Acyclovir topical quantity limit — 15 per 30 days
Productacyclovir topical ointment 5% — QL 15 per 30 days
Formulary tier/contextListed with Requirements Limits = QL in topical antivirals section
Coverage implicationRequests exceeding QL may be reviewed for medical necessity per documentation guidance
inv-31: Nystatin/topical powder quantity limit — 240 per 30 days
Productnystatin topical powder 100,000 unit/gram — QL 240 per 30 days
Related topical entriesTopical antifungals show QL examples such as mupirocin 44 per 30 days and other QLs per day or per 30 days
Formulary contextTopical powders/creams display QL in Requirements Limits column
inv-32: Baqsimi / glucagon kit quantity limit — 4 per 30 days
BAQSIMI nasal spray 3 mgQL 4 per 30 days
Glucagon emergency kit (human)QL 4 per 30 days
Formulary noteEmergency glucagon products are documented with QL entries in the formulary table
inv-33: Quantity limits examples — SHINGRIX QL 1 per 30 days; biologics as per-day fractions
SHINGRIX (vaccine)QL 1 per 30 days (ACA-designated) — example
BiologicsMany biologics display fractional per-day QL values (e.g., 0.129 per 1 day in selected entries)
Provider actionProducts with QL require adherence to listed quantities; PA may also apply for biologics
inv-34: Quantity limits examples — 2 per 1 day; 60 per 30 days; 1 per 273 days; etc.
Common examplesQL 2 per 1 day; QL 60 per 30 days; QL 1 per 273 days — shown in contraceptive/device and other product rows
Emergency contraceptionlevonorgestrel oral tablet 1.5 mg — QL 3 per 30 days (example of 30-day QL)
Long-interval deviceANNOVERA vaginal ring — QL 1 per 273 days (device-specific QL)
Provider Actions and Authorization Requirements
Prior Authorization
Prior Authorization Required — Flagged Products
Certain medicines listed in the drug table are designated with requirement flags (for example: PA, S, ST, QL, ONC, ACA). When a product is marked PA (Prior Authorization) the prescriber or member must obtain prior authorization from HealthPartners before the drug will be covered under the pharmacy benefit. Failure to secure required PA may result in claim denial or non‑coverage.
- PA indicates Prior Authorization is required before coverage.
- S indicates specialty routing or specialty program requirements.
- ST indicates Step Therapy — preferred alternatives must be tried first.
- QL indicates a Quantity Limit — requests above the listed amount will be reviewed.
Prior Authorization
Prior Authorization Required for Many Agents
Many specialty, oncology, injectable, and select oral agents in the formulary are subject to prior authorization. Examples include oral oncology agents, biologics, palforzia allergy products, select antiviral and specialty antiviral agents, and many GLP‑1 / diabetes agents (liraglutide, semaglutide products, tirzepatide, etc.). For these products the Requirements Limits field will include PA, often together with S (specialty) and/or QL.
- Specialty and oncology agents commonly show PA; some also require specialty routing (S) and have quantity limits (QL).
- Selected antiviral regimens and hepatitis C agents include PA and may also include S.
- Selected GLP‑1 and other diabetes agents are listed with Requirements Limits = PA and may have QLs.
Documentation Required
Documentation and Quantity‑Limit Overrides
Prescribers must submit supporting documentation with PA requests and for any requests that exceed a product’s quantity limit. Documentation should demonstrate medical necessity and include diagnosis, prior therapies tried (including dates and outcomes), relevant lab or clinical data, and rationale for the requested quantity or agent.
- Requests above a QL are reviewed for medical necessity and require documentation of diagnosis and alternatives tried.
- Program‑specific flags (ONC, TD, S, QL) require corresponding documentation per HealthPartners procedures.
- When a product is flagged PA or S, include clinical rationale and any specialty pharmacy routing details in the submission.
Denial Risk
Denial Risk — PA and Quantity Limits
PA and QL flags on the drug list are operational triggers — claims submitted for products marked PA without an approved authorization or for quantities exceeding the listed QL are at risk of denial at point of adjudication. Providers should verify authorization status before dispensing and follow HealthPartners’ PA submission process.
- Claims for PA‑listed drugs may be denied if an authorization is not in place.
- Claims exceeding QL will be subject to review and may be denied without adequate supporting documentation.
- Specialty program flags (S) and step‑therapy flags (ST) can also trigger coverage edits or channeling to a specialty pharmacy.
Step Therapy
Step Therapy and Specialty Program Indicators
Step therapy and specialty program indicators appear on some entries. ST indicates a step‑therapy requirement (for example, certain PCSK9/REPATHA entries), and S indicates specialty pharmacy routing or program participation. Where step therapy applies, members must have trialed required alternatives or obtain an exception/approval.
- ST = Step Therapy; patient must try specified preferred medicines first or obtain approval.
- S = Specialty program or specialty pharmacy routing required.
- If step therapy or specialty routing is listed, include prior treatment history and rationale when requesting PA.
Definitions and Abbreviations
inv-94: Specialty medicines — specialty medicines definition/notes
DefinitionSpecialty medicines: prescribed for chronic/complex diseases, often high-cost, requiring more management and specialty pharmacy fills
Benefit implicationSpecialty medicines are often covered under a different benefit and must be filled at a specialty pharmacy
Administration noteProviders and members should check plan benefits for specialty medicine coverage details
inv-95: Formulary abbreviations — PA, ST, QL, AL, ONC, OP, TD
PAPrior Authorization
STStep Therapy
QLQuantity Limit
ALAge Limit
ONCOncology Benefit
inv-96: PA — Prior Authorization definition
TermPrior Authorization (PA) — coverage requires approval prior to dispensing
ImplicationPrescriber must obtain authorization per plan processes or coverage may be denied
Table usePA appears in the Requirements Limits column next to affected products
inv-97: QL — Quantity Limit definition
TermQuantity Limit (QL) — maximum allowed quantity in specified time period
FormatQL values shown as numeric totals per time (e.g., per 30 days) or as fractional per-day values
Clinical actionRequests above QL reviewed for medical necessity and require supporting documentation
inv-98: S — Specialty or program-specific requirement (table indicator)
IndicatorS — Specialty or program-specific requirement (table indicator) — appears alongside PA/QL for some products
MeaningMay indicate specialty routing, step/supplemental program, or specialty pharmacy handling
ExamplesUsed for oncology and other specialty product rows in the formulary table
inv-99: ACA — Administrative/coverage annotation (table start reference)
TermACA — Affordable Care Act annotation indicating preventive/mandated coverage for specified products
Table usageAppears in Requirements Limits to denote ACA-mandated coverage for vaccines, contraceptives, some smoking cessation products
Coverage implicationACA-designated products may have different coverage rules; see table header and plan details
inv-100: Requirement/limit codes — mapping summary (PA, QL, ONC, TD)
PAPrior Authorization — requires pre-approval before coverage
QLQuantity Limit — numeric limit shown per time period
ONC/TD/SONC = Oncology Benefit; TD = Trial Drug; S = Specialty — program/handling flags
inv-101: PA — PA flag appearing in Requirements Limits
PA flagIndicates prior authorization requirement appearing in the Requirements Limits field
ImplicationClaims without PA may be denied for PA-flagged products
Provider actionObtain PA per HealthPartners processes before dispensing
inv-102: QL — Quantity Limit examples in Requirements Limits
QL examplesQuantity Limits shown numerically (e.g., '1 per 1 day', '4 per 30 days'); may be per day fractions or per 30 days
Table locationQL appears in Requirements Limits column next to product rows
ImplicationRequests exceeding QL will be reviewed for medical necessity
inv-103: ONC — Oncology-related requirement flag
PAPrior Authorization — coverage requires approval before dispensing
UseDenoted beside product entries to indicate PA requirement
ConsequenceFailure to obtain PA may lead to claim denial
inv-104: PA — Prior Authorization definition (re-iterated)
PA (re-iterated)Prior Authorization — requires pre-approval prior to dispensing; appears in Requirements Limits
Provider responsibilitySubmit supporting clinical information when requesting PA
Denial riskClaims may be denied without required PA
inv-105: QL — Quantity Limit (re-iterated)
QL (re-iterated)Quantity Limit — maximum allowed quantity per specified time period (numeric or fractional per day)
ExamplesShown as 'per 1 day' fractions or 'per 30 days' totals in product rows
OverrideRequests above QL require documentation for medical necessity
inv-106: S — Step therapy or supplemental requirement (re-iterated)
S (re-iterated)Specialty designation/step/supplemental requirement used in the table to indicate specialty handling or program-specific rules
ExamplesUsed for hepatitis C, oncology, and other specialty products (e.g., LEDIPASVIR-SOFOSBUVIR marked PA; S)
Operational noteS may indicate specialty pharmacy routing or enrollment requirements
inv-107: PA — Prior Authorization (definition)
PAPrior Authorization — coverage requires approval prior to dispensing (definition)
Table usageFlagged as PA in Requirements Limits column
Provider actionObtain PA per payer procedures before dispensing for PA items
inv-108: QL — Quantity Limit (definition)
QL — definitionQuantity Limit — numeric maximum permitted within specified time period; shown per day or per 30 days
FormatMay appear as absolute count (e.g., 15 per 30 days) or fractional per-day rate (e.g., 0.071 per 1 day)
ReviewOverrides require medical necessity documentation
inv-109: PA — Prior Authorization (definition repeated)
PA (repeated)Prior Authorization — coverage requires approval before dispensing
ImplicationPA appears as a Requirements Limits flag and triggers prior review
DocumentationProviders must supply clinical rationale when seeking PA
inv-110: QL — Quantity Limit (definition repeated)
QL (repeated)Quantity Limit — maximum allowed units per specified time period; may be shown as per day or per 30 days
ExamplesExamples include QL (1 per 1 day) or QL (60 per 30 days)
Provider noteExceeding QL will prompt medical necessity review
inv-111: S — Specialty designation (definition repeated)
S — specialty designationIndicates specialty-managed product; specialty medicines require specialty pharmacy fills
Benefit noteSpecialty medicines often covered under a different benefit than retail drugs
Check planMembers/providers should verify specialty coverage via myHealthPartners or plan details
inv-112: Prior Authorization required for coverage — PA
PA requirementPrior Authorization required for coverage — products marked PA must have authorization before dispensing
ConsequencesFailure to obtain PA may result in the medication not being covered under pharmacy benefits
Provider actionSubmit PA per HealthPartners procedures with supporting clinical information
inv-113: Quantity Limit (numerical limit per time period shown) — QL
QL definitionQuantity Limit — numerical limit per time period shown in Requirements Limits (e.g., '4 per 30 days')
DisplayQLs appear alongside product rows as per-day fractions or per-30-day totals
Override processRequests exceeding QL reviewed for medical necessity and require documentation
inv-114: Step therapy requirement — S
S — step therapyIndicates a step therapy requirement where specified preferred medicines must be tried first
Operational noteIf prior steps not met, prior approval is required before coverage at lower cost-share
Table usageDenoted as 'S' or 'ST' in Requirements Limits for some products
inv-115: Coverage references/conditions — ACA / SC references present in table header
Coverage referencesACA / SC annotations appear in table header to indicate special coverage conditions (e.g., ACA-mandated preventive coverage)
InterpretationRefer to table header and plan details to interpret ACA/SC annotations
ExamplesVaccines and certain contraceptives are marked ACA in the formulary
inv-116: QL — QL examples (4 per 30 days)
Example QL valueQL 4 per 30 days (e.g., BAQSIMI, glucagon kits) — shown in the formulary table
InterpretationQL values may be per 30 days for emergency medications and per day fractions for chronic injectables
Provider actionAdhere to listed QL or submit documentation for exceptions
inv-117: PA — PA = prior authorization required
PA — summaryPA = prior authorization required (flag in Requirements Limits)
ActionObtain pre-approval per payer processes; lack of PA may cause denial
Where shownAppears next to many antiviral, specialty and other high-cost products in the formulary
inv-118: S — specialty designation / pharmacy requirement
S — specialty markerIndicates specialty designation, program or step requirement; may trigger specialty routing
ExamplesUsed for some hepatitis C and oncology agents in Requirements Limits
Provider implicationProducts marked S may require specialty pharmacy fill or program enrollment
inv-119: PA — PA indicated in Requirements Limits
PA indicator in tablePA is indicated in the Requirements Limits column for applicable products
ImplicationWhen PA is present, coverage depends on prior approval
Provider actionFollow payer PA submission processes and provide clinical justification
inv-120: QL — Quantity Limit (e.g., 1 per 1 day)
QL — numeric formatQuantity Limit entries such as '1 per 1 day' or fractional per-day values appear in Requirements Limits
ExamplesSome stimulant or migraine therapies show fractional/day QLs (e.g., 0.429 per 1 day)
Clinical noteQLs limit dispensed quantity; exceptions require documentation
inv-121: S — Specialty drug designation appears in Requirements Limits
S in Requirements LimitsS appears in Requirements Limits to denote specialty-managed products
ExamplesAppears for oncology, biologic and other specialty agents
Operational effectMay require specialty pharmacy dispensing or program enrollment
inv-122: ACA — ACA-related coverage flag in Requirements Limits
ACA mappingACA indicates Affordable Care Act-related coverage notation present in Requirements Limits for some agents
UsageUsed for vaccines, contraceptives, smoking cessation products in table examples
Coverage implicationACA-marked products may have mandated coverage per federal guidelines
inv-123: Requirements Limits abbreviations — ACA, PA, QL mapping
Abbreviations listRequirements Limits abbreviations include ACA, PA, QL (used in table to denote coverage/authorization rules)
Interpretation adviceRefer to table header and plan documentation for full meaning and implications
ExamplesACA — preventive; PA — prior authorization; QL — quantity limit
inv-124: Requirements Limits codes — ACA, PA, QL, S explained
Codes explainedRequirements Limits codes (ACA, PA, QL, S) indicate coverage restrictions such as ACA-mandated coverage, prior authorization, quantity limits, or specialty/site requirements
Provider actionFollow the indicated requirement for each product row to determine coverage and authorization steps
Where shownCodes appear in the Requirements Limits column throughout the formulary table
Initial Therapy Criteria
Step Therapy Rules
| Step therapy statement | Notes / implication |
|---|---|
| Try specified preferred medicines first | |
| A medicine with step therapy will be covered only if the member has already tried required prior medicine(s); if not, prior approval from HealthPartners is required before coverage at the lower cost-share. |
| Step therapy / specialty flag | Examples / implication |
|---|---|
| 'S' indicator present on some hepatitis C agents | |
| Examples include LEDIPASVIR‑SOFOSBUVIR and MAVYRET which are listed with Requirements Limits = PA; S, indicating specialty/step program requirements before coverage. |
| Flag(s) | Interpretation / example agents |
|---|---|
| 'TD' and 'S' flags on oncology/specialty agents | |
| Antineoplastic entries (e.g., abiraterone, everolimus) include PA; ONC; TD; S — indicating specialty distribution or program enrollment may be required as part of access prior to coverage. |
| Flag | Coverage implication / examples |
|---|---|
| 'TD' or 'ONC' flags for oncology agents | |
| Targeted cancer therapies (ROZLYTREK, TAGRISSO) and other oncology drugs show ONC or TD flags; these denote oncology benefit/specialty handling and may require specialty routing or program steps before coverage. |
| Designation | Meaning / examples |
|---|---|
| 'S' designation on products | |
| Several products (for example AUSTEDO, EVRYSDI) carry 'S' indicating step therapy or specialty clinical edit applies and must be followed per formulary requirements. |
| Observation | Implication |
|---|---|
| No explicit step sequences listed in some sections | |
| Portions of the formulary list products with PA, QL, and Tier designations but do not provide step-by-step therapy algorithms; utilization management is implemented via PA, QL, and tiering where present. |
| Step therapy flag | Example / note |
|---|---|
| 'ST' indicated for some agents | |
| REPATHA SureClick and syringe entries are labeled ST; QL (0.071 per 1 day), indicating step therapy (ST) is required before coverage at the listed benefit level. |
| 'S' specialty/step marker | Examples |
|---|---|
| 'S' required for certain specialty oral agents | |
| Examples include carglumic acid and deferasirox which are listed with Requirements Limits = PA; S, indicating specialty program or step requirements and that PA/submission is required. |
| PA noted | Examples (GLP‑1 / diabetes agents) |
|---|---|
| Prior authorization indicated for several GLP‑1 / diabetes agents | |
| MOUNJARO, liraglutide and OZEMPIC entries are shown with Requirements Limits = PA and have numeric QL values (e.g., liraglutide QL 0.3 per 1 day), indicating PA applies for these agents. |
| Coverage annotation | Implication / examples |
|---|---|
| 'ACA' or 'S' on vaccines and biologics | |
| Some vaccines and biologics are annotated ACA (Affordable Care Act preventive coverage) or S (specialty); examples include AREXVY and PALFORZIA levels which show ACA or PA; S markings implying special coverage pathways or program requirements. |
| Observation | Interpretation |
|---|---|
| Step therapy often implied rather than explicit | |
| In many formulary sections step therapy is implied by tiering and presence of PA/S/QL flags; explicit step-by-step sequences are not present within the extracted chunks. |
Quantity Limits (Selected Items)
Site of Care and Specialty Pharmacy Routing
Billing Rule
Fill specialty medicines at specialty pharmacy when required
Certain specialty medicines and oncology drugs must be filled at a specialty pharmacy; prescribers should route prescriptions to the specialty pharmacy as indicated by the formulary.
Note
Billing Rule
Follow 'S' specialty/site routing for ophthalmic products
Some ophthalmic products include a specialty/site 'S' designation and may require specialty routing or site‑specific handling; follow the 'S' designation when submitting and routing prescriptions.
Background
The formulary groups medicines by therapeutic category and assigns cost-sharing tiers (Tier 1–7) to determine member out-of-pocket responsibility. Specialty medicines — typically high-cost products for chronic or complex conditions — are identified and commonly managed through specialty pharmacy channels and different benefit rules. The table uses requirement codes (for example PA = prior authorization; QL = quantity limit; ACA = Affordable Care Act preventive designation; S = specialty or step/program indicator) to convey administrative coverage requirements that affect how and when a specialty medicine will be covered.
Policy Summary
PayerHealthPartners
Policy2026 Formulary (Drug List) — Pharmacy Coverage Criteria
Policy CodePolicy N/A
Change TypeAnnual formulary publication (no material changes)
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization for any product listed with 'PA' before dispensing to ensure coverage.
SourceLink
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