CurrentHealthPartnersPolicy N/A

HealthPartners 2025 Formulary (Drug List) - Coverage Criteria for Specialty and Retail Drugs

This document is the HealthPartners 2025 drug list (formulary) describing covered medicines, tiers, specialty drugs, and common limits/restrictions and prior authorization/step therapy rules for plan members and providers.

Policy Summary

PayerHealthPartners

PolicyHealthPartners 2025 Formulary (Drug List) - Specialty and Retail Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain prior authorization and document diagnosis, prior alternatives tried, and rationale when requesting coverage for medicines flagged with PA or QL.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-10-01Formulary effective date

QuarterlyReview frequency

SpecialtySpecialty handling

PA / QLAuthorization types

PA/QLOpioid restrictions

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Coverage Criteria & Controls

Covered with conditions

Formulary coverage subject to limits and program rules

Formulary general requirements: Coverage follows the formulary tiers; medicines may be subject to prior authorization (PA), step therapy (ST), age limits (AL1/AQ1), quantity limits (QL), specialty designation (S), Oncology benefit routing (ONC/Oh/OncoHealth), or Trial Drug program (TD) as indicated in Limits & Restrictions.

Providers must follow PA/ST/QL/AL rules noted on the drug list.

Trial Drug Program: New prescriptions for certain medicines may be managed under the Trial Drug Program limiting the first 6 fills to a smaller than one‑month supply; continuation beyond the trial period follows program rules.6 fills

If covered by a copay, no more than one copay is charged per one‑month supply during the trial period.

Coverage controls (PA/QL/Tier)

Coverage and utilization management controls applied to listed drugs

Formulary controls: Drugs are assigned a formulary tier; certain formulations and strengths require prior authorization (PA) and/or have quantity limits (QL) with specified per‑day or per‑fill maximums.

Examples in the listing include ER opioid formulations and other products annotated as QL, PA or QL PA; see Limits & Restrictions for product‑level details.

Coverage contingent on PA/QL/ONC

Coverage subject to oncology benefit and utilization controls

Oncology benefit controls: Product is covered under the Oncology (ONC) / OncoHealth specialty benefit but requires adherence to Limits & Restrictions including prior authorization (PA), quantity limits (QL), and trial drug or specialty routing flags (TD, OH, S) as indicated.

Specific clinical eligibility criteria are not legible in this fragment; follow OncoHealth/ONC PA processes.

Oncology specialty coverage with limits

Covered under the Oncology Specialty (ONC/OncoHealth) benefit when benefit and utilization restrictions are met

Oncology benefit and utilization limits: Drug is designated on the OncoHealth/ONC oncology specialty benefit and is subject to Limits & Restrictions (e.g., QL, PA, TD) and any daily capsule/tablet limits noted in the formulary.

Daily capsule limits (examples: 'CAPS 1 DAY' / '3 CAPS 1 DAY') appear in the listing; confirm applicable limit in Limits & Restrictions.

Coverage summary with utilization controls

Coverage is presented under the Oncology Benefit (ONC) with limits and restrictions applied

Formulary placement and utilization controls: Branded oncology oral agents (example: cyclophosphamide 50 mg capsule in this fragment) are placed on the ONC/OncoHealth benefit (Tier 4 in the listing) and have Limits & Restrictions including quantity limits and prior authorization.

Documented quantity phrasing such as 'CAPS 1 DAY' and '3 CAPS 1 DAY' is used in the listing; consult Limits & Restrictions for enforcement and PA requirements.

Oncology specialty coverage controls

Coverage under the OncoHealth oncology specialty benefit is subject to the following designations and controls:

Formulary management: Drug is listed on the OncoHealth oncology specialty formulary with benefit and tier placement noted (e.g., Tier 4).Tier 4

Tier shown in the formulary listing; clinical criteria not present in these chunks.

Utilization controls: Limits & Restrictions apply including QL (quantity limits), PA (prior authorization), and other modifiers (TD, OH, ONC) as annotated on the drug line.see modifiers

Exact approval conditions and clinical criteria are in the full policy/PA documents.

Daily quantity statements: Listing includes per‑day quantity descriptors such as 'CAPS 1 DAY' and '3 CAPS 1 DAY' which are referenced as limits in the formulary.

Oncology specialty coverage

Covered under the OncoHealth/ONC specialty benefit with utilization management

Formulary and management: Drug (e.g., cyclophosphamide 50 mg capsule — brand) is listed on the OncoHealth/ONC specialty benefit and is subject to Limits & Restrictions including QL, PA, TD and OncoHealth (OH) routing flags; 'CAPS 1 DAY' appears in the listing.

Explicit clinical medical‑necessity criteria are not present in these chunks; PA documentation requirements apply.

Coverage flags

Coverage and utilization controls are indicated by shorthand flags for each drug

Authorization & routing flags: Formulary entries are annotated with one or more shorthand flags: PA (prior authorization), QL (quantity limit), ONC (Oncology benefit), OH / OncoHealth (oncology program routing), S (specialty pharmacy), and TD (Trial Drug designation).

These flags indicate required administrative steps (PA, specialty routing, QL enforcement); see full policy for criteria and documentation instructions.

Specialty medicines are managed differently than routine retail drugs. Per the formulary, specialty medicines must be dispensed through a specialty pharmacy and may be covered under a different benefit than non-specialty retail prescriptions; providers and pharmacies should verify member-specific benefit routing before prescribing or dispensing.

No explicit policy-level exclusions are listed in the available fragment. The document excerpt indicates coverage entries and benefit routing but does not present any standalone exclusion statements.

The fragment reviewed does not include explicit clinical exclusion language tied to the listed oncology products; entries focus on benefit designation and utilization flags rather than enumerated clinical exclusions.

Within these chunks there are no legible exclusion statements. Content is primarily OncoHealth/ONC routing and limits & restrictions notation rather than exclusion rules.

No explicit clinical exclusions are present in the cited excerpt; the text repeatedly annotates oncology routing and utilization modifiers without listing exclusion criteria.

These chunks do not contain explicit exclusion statements; they instead repeat OncoHealth/Oncology specialty routing, trial-drug and modifier flags without discrete exclusion language.

Portions of the source around this index are corrupted or highly repetitive; content is duplicated and not reliably legible for policy text extraction.

Requests that exceed the stated quantity limits (QL) will be reviewed for medical necessity and may be denied if the requester does not provide appropriate supporting documentation such as diagnosis, prior alternatives tried, or evidence of efficacy/safety at the requested quantity.

The segment emphasizes formulary tiering and utilization controls: many products are shown with Tier placement and shorthand flags such as PA (prior authorization) and QL (quantity limit). Several entries also include oncology routing flags (e.g., ONC, OH/OncoHealth) indicating specialty benefit handling.

The examined fragment does not list explicit conditions that would be labeled 'Not Medically Necessary' (NMN). Instead, it documents benefit routing and usage flags (PA, QL, TD, ONC) without providing discrete NMN determinations.

No explicit 'Not Medically Necessary' statements are present in these chunks; the content focuses on limits and specialty program designations rather than NMN rulings.

The source material in this window does not contain explicit NMN determinations. Coverage language is framed around OncoHealth/ONC routing and utilization modifiers instead.

No explicit 'Not Medically Necessary' determinations are documented in the cited excerpts; entries describe the drug as listed under the OncoHealth/ONC specialty benefit with associated limits and prior authorization requirements.

These chunks show repeated shorthand flags (PA, QL, TD, ONC, OH, S) used to indicate authorization and routing. They do not include explicit NMN statements; clinical acceptance or denial determinations are not provided here.

The fragments include trial/step and specialty flags (e.g., TD, S, OH) for certain oncology agents but do not list explicit 'Not Medically Necessary' conditions or determinations within the visible text.

Drug Listings, Codes & Limits

Sample listed drugs with limitsmixed

dihydroergotamine 1 mg/ml amp	listed with QL PA; 24 MG (AMPS) 28 DAYS
ERGOMAR	Tier 3; LIMITS & RESTRICTIONS = QL PA; 20 TABS 30 DAYS
acetaminop-codein 240-24 mg/10	LIMITS & RESTRICTIONS = QL ALI; 60 ML 1 DAY; At least 12 yrs old
fentanyl (12-100 mcg/hr patches)	LIMITS & RESTRICTIONS = QL ALI = PA
hydrocodone-acetaminophen (various strengths)	LIMITS & RESTRICTIONS = QL ALI; 8 TABS 1 DAY
hydromorphone 2 mg tablet	LIMITS & RESTRICTIONS = QL ALI; 8 TABS 1 DAY
hydromorphone 3 mg suppos	LIMITS & RESTRICTIONS = QL ALI; 8 SUPP 1 DAY

Drug listing (no billing codes in this segment)mixed

not provided

This document segment does not include CPT/HCPCS/ICD-10/NDC codes — only drug names, tiers, PA/QL flags and quantity limits.

Utilization/control codes from fragmentmixed

PA	Prior Authorization
QL	Quantity Limit
TD	Tier/Diagnosis or other utilization designation (document fragment shows 'TD')
ONC	Oncology benefit designation
OH / OncoHealth	OncoHealth / OH specialty program identifiers referenced in document

Formulary identifiersmixed

N/A	No CPT/HCPCS/ICD codes present in this fragment; only product name and formulary indicators.

Formulary modifiers and management codesmixed

QL	Quantity Limit (documented in limits & restrictions)
PA	Prior Authorization required
TD	Therapeutic/Trial designation (modifier shown)
OH	OncoHealth specialty designation
ONC	Oncology benefit designation

Oncology specialty drug listingNDC|drug_nameCovered

CYCLOPHOSPHAMIDE 50 MG CAPSULE (BRAND)

Listed oncology specialty drug (brand)

Oncology oral chemotherapy examplesNDC | drug-name

CYCLOPHOSPHAMIDE 50 MG CAPSULE (BRAND)

Listed medication with repeated entries and limits

Specific branded oral oncology agents and limitsNDC | drug-nameCovered

IMBRUVICA 140 MG CAPSULE	Listed with 'PA S OH' limits
IMBRUVICA 420 MG TABLET	Listed with 'QL PA S OH' and '1 TAB 1 DAY' quantity
IMBRUVICA 70 MG/ML SUSPENSION	Listed with 'QL PA S' and '6 ML 1 DAY' quantity
KISQALI 200 MG DAILY DOSE	Listed with 'QL PA ONC' and '21 TABS 28 DAYS'
KISQALI 600 MG DAILY DOSE	Listed with 'QL PA' and '63 TABS 28 DAYS'

Classic cytotoxic oral and injectable agentsdrug-nameCovered

METHOTREXATE (2.5 MG TAB, 50 MG/2 ML VIAL, 250 MG/10 ML VIAL)	Listed with PA/ONC/S/OH flags
MERCAPTOPURINE 50 MG TABLET	Listed with PA/ONC/S/OH flags
MELPHALAN	Listed with PA/ONC/S/OH and OncoHealth routing

Quantity/age limits (examples)

Dihydroergotamine 1 mg/mL ampules24 MG (AMPS) per 28 days

ERGOMAR (ergotamine)20 TABS per 30 days

Acetaminophen-codeine formulations60 mL / 1 day; minimum age: at least 12 years

Per-day quantity limits examples

Oxycodone liquid formulations40 mL / 1 day

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required — some medicines require prior authorization as noted in Limits & Restrictions

Prior authorization (PA) is required for many medicines and product formulations listed on the HealthPartners drug list. Extended‑release (ER) products and certain formulations (e.g., ER tablets/capsules, specialty injectables, oncology agents) are frequently designated with PA and/or specialty (S) flags and will not be covered at the preferred benefit level without an approved authorization.

PA = Prior Authorization Required; ST = Step Therapy; QL = Quantity Limit; ONC = Oncology benefit; OH = OncoHealth routing; TD = Trial Drug program; S = Specialty
ER/formulations requiring PA: extended‑release opioids, tramadol ER, oxymorphone ER, methadone products, select anticonvulsant ER formulations — see drug list entry for specific product-level PA or QL
Examples of PA and quantity-limit (QL) combinations: tramadol ER (QL, PA), hydromorphone ER (PA), oxycodone IR high strengths (PA), select topical or specialty biologics (QL PA S)
Oncology/specialty products: many oncology agents and supportive products are routed to the OncoHealth program and require PA (flags: ONC, OH, TD, S). Examples: EMEND (OH OncoHealth), ondansetron (OH OncoHealth), aprepitant (OH OncoHealth), select antifungals (posaconazole, voriconazole — PA), and numerous oral/infusible oncologics (nilotinib, imatinib, IBRANCE, INLYTA, etc.)
Hemophilia/coagulation and other specialty products (e.g., AFSTYLA, ALPHANATE, ALPROLIX, ELOCTATE, Hemlibra, etc.) are Specialty distribution items and carry PA S flags

Initial Therapy Coverage Rules

Initial coverage notes

Coverage under Oncology benefit with restrictions

Initial coverage conditions: Branded cyclophosphamide 50 mg capsules are managed under the OncoHealth/ONC program and are subject to prior authorization and quantity limits (documented as up to 3 capsules per day in the listing).3 caps/day

No diagnosis‑specific medical necessity criteria are legible in this fragment; follow OncoHealth PA procedures and submit required documentation.

Initial therapy / dosing notes

Dosing/quantity descriptors present in formulary listing

Daily quantity: Formulary shows per‑day quantity descriptors such as 'CAPS 1 DAY' and '3 CAPS 1 DAY' used to indicate daily supply/quantity expectations for listed oncology oral agents.as listed

Step Therapy & Trial Drug Designations

Requirement	Notes
Must try required alternative(s) before coverage
HealthPartners covers medicines with step therapy only after documented trial and failure or intolerance of the required prior agents; provider must obtain approval to receive lowest copay/coinsurance

Statement	Implication
No explicit multi-step sequencing provided in this excerpt
Listings show tiering and PA/Specialty flags but do not specify ordered step sequences or named prerequisite agents in this fragment

Product example	Dispensing frequency / Limit
NUCALA (syringes, auto‑injector)
1 syringe / 28 days; 1 auto‑injector / 28 days (as listed)

Example products	Utilization controls (flags)
SKYRIZI (pens, on‑body, cartridges)
QL PA S noted (quantity limits, prior authorization, specialty) and specific pen/syringe/cartridge day limits
Pimecrolimus; tacrolimus; select anticonvulsants (carbamazepine, FYCOMPA)
Entries show QL PA S and QL ST flags indicating specialty PA and quantity limits (and occasional step‑therapy shorthand)

Oncology designation	Flag meaning / examples
ONC / OncoHealth / OH / S / TD flags
Used to route drugs to the Oncology/OncoHealth specialty benefit and indicate trial‑drug or specialty handling (examples: BALVERSA, BRUKINSA, capecitabine entries)

Reference	Observation
TD / Step references present
Document shows TD/Trial designations adjacent to oncology entries but does not provide explicit ordered step sequences or named prior agents in this fragment

Restriction types	Context
PA / QL / TD
These utilization controls are applied as part of the OncoHealth/ONC specialty benefit and must be met for coverage (per Limits & Restrictions entries)

Statement	Consequence
No explicit steps described in this excerpt
The excerpt contains tiering and program flags but does not present a step‑by‑step therapy algorithm

Precoverage requirements	Applies to
Prior authorization and OncoHealth utilization management must be satisfied before coverage
Applies to drugs routed to the Oncology/OncoHealth specialty benefit (examples in listing: cyclophosphamide brand entries show QL PA ONC flags)

Flag	Interpretation
TD (Trial Drug) flags
Presence of TD or TD S suggests trial/step programs or limited initial fills, but explicit step sequences are not provided in this fragment

Product	Flagged designation
Nilotinib (nilotinib hcl / tartrate entries)
Marked with 'Trial Drug', 'TD' and 'TD S' flags alongside ONC/PA/QL indicators, indicating a trial‑drug designation though explicit step requirements are not shown

Quantity Limits & Dispensing Restrictions

dihydroergotamine 1 mg/ml amp — 24 MG (AMPS)

Dihydroergotamine 1 mg/mL ampules24 MG (AMPS)

Citation contextListed with LIMITS & RESTRICTIONS = QL PA and 24 MG (AMPS) 28 DAYS

Tier infoTIER = 3 as shown in listing

ERGOMAR — 20 TABS

ERGOMAR (ergotamine)20 TABS

Limits & RestrictionsListed as QL PA with 20 TABS per 30 days

TierTIER = 3 in the listing

Site of Care & Specialty Distribution

Note

Background

Background: Specialty medicines are typically high‑cost and used to treat chronic or complex conditions; they often require additional management and must be dispensed via a specialty pharmacy. The formulary and specialty benefit (OncoHealth/ONC) route certain oncology agents to specialty management and are reviewed by the Pharmacy & Therapeutics committee on a recurring schedule.

Formulary Abbreviations & Definitions

Policy Summary

PayerHealthPartners

PolicyHealthPartners 2025 Formulary (Drug List) - Specialty and Retail Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain prior authorization and document diagnosis, prior alternatives tried, and rationale when requesting coverage for medicines flagged with PA or QL.

SourceLink

On This Page

1-3 caps per day as listed

These statements may reflect typical dosing or enforced QL entries; confirm via Limits & Restrictions.

Oxycodone IR 10 mg tablet5 TABS / 1 day

Buprenorphine–naloxone films/tablets2–3 films/tabs per day (formulation-dependent)

Examples of quantity thresholds

Methylphenidate ER (various strengths)2 CAPS per day or 1 CAP per day depending on strength

Methylphenidate ER 30 mg (authorized generic)3 TABS 1 DAY = 2 CAPS 1 DAY

Mupirocin 2% ointment44 GM per 1 fill

Daily capsule limit — 3 caps per day

Daily capsule limit (document phrasing)3 caps per day

Associated designationListed under OncoHealth/ONC with CAPS 1 DAY phrasing

TierTier 4 (as listed for OncoHealth products)

Daily capsule limit — 3 CAPS per day

Daily capsule limit (repeated)3 CAPS per day

ContextAppears in Limits & Restrictions for branded oncology product entries

Routing flagsAssociated with ONC / OncoHealth notation

Daily capsule quantity — 3 CAPS 1 DAY; CAPS 1 DAY

Daily capsule quantity phrasing'3 CAPS 1 DAY' and 'CAPS 1 DAY' used in listing

ImplicationMay represent per-day maximums applied under oncology specialty benefit

Document noteSpecific clinical criteria not present in fragment; quantity wording repeated

Per-day capsule/tablet limit examples

IMBRUVICA 420 mg tablet1 TAB 1 DAY (listed quantity)

KISQALI dosing formats63 TABS per 28 days; 21 TABS per 28 days for 200 mg dose

General examplesListings show '1 TAB 1 DAY', '3 CAPS 1 DAY', '4 CAPS / 1 DAY', '6 ML 1 DAY'

Standard oral supply format — 63 TABS per 28 days

Standard oral supply format63 TABS per 28 days (commonly used for oral oncology agents)

Alternate pack sizes21 TABS per 28 days referenced for some dosing regimens

UseApplied as quantity limits under OncoHealth/ONC listings

Authorization flags present in the drug list (examples): PA, QL PA, PA S, QL PA S, OH OncoHealth, ONC, TD — shorthand flags indicate the full Limits & Restrictions rules in the policy

Quantity-limit denial risk: requests above listed QL will be reviewed and may be denied without documentation of medical necessity, prior therapies tried, or clinical rationale

Utilization controls may trigger denial: absence of required PA, exceeding QL, not meeting ST requirements, or wrong benefit routing (ONC vs. pharmacy) can lead to denial

Documentation Required

Prior authorization documentation

Providers must supply documentation when requesting exceptions to QLs or when submitting PAs. Typical required documentation includes the diagnosis, prior alternatives tried and dates, dosing and quantity rationale, evidence of efficacy/safety for the requested dose or duration, and benefit routing (e.g., ONC/OncoHealth) when applicable.

Quantity‑limit documentation: include indication, previous use at quantities within the limit, and why a larger quantity is clinically necessary
PA documentation: diagnosis, previous therapies/trial dates, clinical notes supporting need, and any relevant lab or imaging results
Dispensing/quantity detail: record required unit/pack size (pens, syringes, cartridges, vials) and requested days’ supply to match drug list QL (e.g., 1 syringe = 84 days, 2 pens = 28 days)
Oncology/OncoHealth routing: include oncology diagnosis, treatment intent, and any trial‑drug (TD) documentation if flagged as a trial drug
Shorthand flags: follow the full Limits & Restrictions text on the drug list — shorthand (PA, QL, ONC, OH, TD, S) does not replace required clinical documentation

Denial Risk

Quantity limit denial risk

Quantity limits (QL) on the drug list are actively enforced. Requests exceeding the stated QL are subject to medical‑necessity review and may be denied without adequate clinical justification.

Requests above QL will be reviewed for diagnosis, prior alternatives tried, evidence of efficacy at the requested dose, and prior use within QL
Examples: mupirocin 2% ointment QL = 44 g per fill; various oral opioids have per‑day tab/capsule limits
If approval is granted for an over‑QL request, documentation must be retained and presented upon audit or re‑review

Step Therapy

Step Therapy Requirement

Step therapy (ST) applies to some products. Where ST is indicated, coverage at the preferred benefit requires documented trials of listed alternative agents; the drug list does not always show the full step sequence — follow the Limits & Restrictions criteria or PA form.

ST flag indicates one or more required prior agents; absence of required trials may result in denial
Many specialty/onco products include TD (trial drug) or ST designations — see product Limits & Restrictions for specifics
If step‑therapy details are not explicit on the drug list segment, check the full policy/PA criteria or contact the payer

Prior Authorization

PA / OncoHealth required for selected agents

Oncology and specialty agent routing: multiple agents are managed by the OncoHealth program and/or require specialty distribution. These entries commonly include combined flags (PA, ONC, OH, TD, S) and require program enrollment or OncoHealth review prior to coverage.

OncoHealth-managed examples: EMEND (OH OncoHealth), ondansetron (OH OncoHealth), aprepitant (OH OncoHealth), select antifungals (posaconazole, voriconazole — PA), and oral oncologics (nilotinib, imatinib, IBRANCE, INLYTA, KISQALI, etc.)
Many branded chemotherapy and supportive care drugs show ONC/TD/OH flags — these require PA and are frequently subject to QL and trial‑drug rules
Specialty distribution/hemophilia examples: AFSTYLA, ALPHANATE, ALPROLIX, ELOCTATE, HEMLIBRA, FEIBA, IDELVION, JIVI, etc. are PA S Specialty items

Denial Risk

Limits & restrictions — documentation and denial risk

Limits & Restrictions on the drug list are authoritative. Abbreviated flags beside products (PA, QL, ST, ONC, OH, TD, S) indicate that utilization management applies; providers must follow the full policy text for criteria and submission instructions.

Authorization flags present: PA, QL PA, PA S, QL PA S, ONC, OH, TD, ST — each implies specific operational requirements
Prior authorization and quantity‑limit triggers: presence of PA or QL on the product entry means claims may be denied without prior approval or adequate documentation
Denial triggers: missing PA approval, exceeding QL, failing ST requirements, incorrect benefit routing (e.g., oncology drug billed to regular pharmacy) are common denial reasons

These descriptors appear repeatedly for cyclophosphamide in the extract; consult Limits & Restrictions for how QL is applied operationally.

Selected opioid formulations — examples of per-day limits

Opioid formulation examplesPer-day limits include 60 mL/1 day (liquid), 8 tabs/1 day (some IR), 8 supp/1 day (suppositories)

Age restrictionsMany opioid entries include minimum age (e.g., at least 12 years) and QL/PA flags

Authorization flagsEntries commonly show QL or PA (or both) for opioid formulations

Multiple per-day caps specified — various examples

Multiple per-day caps documentedExamples across listings: '3 CAPS 1 DAY', '2 CAPS 1 DAY', '1 TAB 1 DAY' depending on product and strength

Formulation dependencePer-day cap varies by formulation (capsules, tablets, films, suppositories)

Age-dependent entriesSeveral entries pair per-day caps with minimum age statements (e.g., 12 yrs)

methylphenidate ER — 2 caps/day or 1 cap/day depending on strength

Methylphenidate ER dosing limits2 caps/day or 1 cap/day depending on strength and formulation

Authorized genericsSome authorized generics list equivalent tab/cap conversions (e.g., 3 TABS 1 DAY = 2 CAPS 1 DAY)

Limits & Restrictions flagQL applies across many methylphenidate ER entries

sodium oxybate — 18 ML /1 DAY

Sodium oxybate (SXB)18 mL / 1 day

Specialty designationListed with QL PA S (specialty and prior authorization)

ContextAppears with wakefulness-promoting agents and specialty handling

mupirocin 2% ointment — 44 GM / 1 FILL

Mupirocin 2% ointment44 GM per 1 fill

Limit typeQuantity limit applied to topical formulation

Dispensing noteDispensing must conform to QL as listed

ivermectin 3 mg tablet — 40 TABS RX

Ivermectin 3 mg tablet40 TABS per prescription (RX)

Limit typeQuantity limit (QL) applied to oral anthelmintic

Listing contextIncluded under anthelmintics with QL flag

fosfomycin tromethamine — QL 3 PACKETS RX

Fosfomycin tromethamineQL 3 PACKETS per prescription (RX)

Unitpackets per RX

Tier contextListed under urinary anti-infectives with QL

SKYRIZI (various presentations) — pens/syringes/cartridges limits vary by presentation

SKYRIZI (various presentations)Limits vary by presentation: PENS 28 DAYS; 1 SYRINGE 84 DAYS; 1 CARTRIDGE 56 DAYS; PEN 84 DAYS

Specialty flagEntries show QL PA S (quantity limit, prior authorization, specialty)

Dispensing frequencyPresentation-dependent dispensing intervals noted in listing

enoxaparin syringes/vials — 2 SYRINGES 1 DAY or 2 VIALS 1 DAY

Enoxaparin syringes/vials2 SYRINGES 1 DAY or 2 VIALS 1 DAY (product dependent)

CategoryHeparins / enoxaparin listed with QL

Use noteProduct-dependent packaging determines whether limit applies to syringes or vials

ELIQUIS / XARELTO — specific tablet counts per day or treatment start quantities

ELIQUIS / XARELTO examplesSpecific tablet counts per day or treatment-start quantities (e.g., XARELTO DVT-PE treat start = 51 TABS / 30 days)

Formulation notesDifferent strengths and treatment phases have distinct QL entries

Age/indicationSome entries include age or indication-based limits

gabapentin various strengths — example limits

Gabapentin (various strengths)Examples include 12 CAPS per day and 72 mL per day for liquid formulations

Gabapentin 250 mg/5 mL solution72 mL per day

Gabapentin 400 mg capsule9 capsules per day

gabapentin 250 mg/5 ml soln — 72 mL per day

Gabapentin 250 mg/5 mL solution72 mL per day

ContextListed as QL PA S for certain specialty packaging

UnitmL per day

gabapentin 400 mg capsule — 9 capsules per day

Gabapentin 400 mg capsule9 capsules per day

Limit typeDocumented as per-day capsule cap in listing

Associated flagsQL PA S appears adjacent to gabapentin entries

pregabalin 20 mg/ml solution — 30 mL per day

Pregabalin 20 mg/mL solution30 mL per day

Limit typeDaily volume limit for liquid formulation

FlaggingListed with QL PA S in excerpt

lacosamide (liquid) — 40 mL per day

Lacosamide (liquid formulations)40 mL per day

Rufinamide (various forms)200 mg tablet: 16 tabs/day; 40 mg/mL suspension: 80 mL/day; 400 mg tablet: 8 tabs/day

Limit contextQL entries apply and are strength/formulation specific

rufinamide — multiple tablet/suspension daily limits

Rufinamide formulations — examples200 mg tablet: 16 tablets/day; 40 mg/mL suspension: 80 mL/day; 400 mg tablet: 8 tablets/day

QL/PA flagsListed with QL PA for some strengths

Unittablets or mL per day depending on formulation

liraglutide — multiple pack size limits referenced

Liraglutide pack-size limitsExamples: 3 pens (9 mL) / 30 days; 5 pens (15 mL?) / 30 days (varies by listing)

MOUNJARO4 pens (2 mL) / 28 days

OZEMPIC1 pen (3 mL) / 28 days

MOUNJARO — 4 pens (2 mL) / 28 days

MOUNJARO (tirzepatide)4 pens (2 mL) / 28 days

OZEMPIC (semaglutide)1 pen (3 mL) / 28 days

RYBELSUS (oral semaglutide)1 tablet per day

OZEMPIC — 1 pen (3 mL) / 28 days

OZEMPIC1 pen (3 mL) per 28 days

ContextListed under incretin mimetics with pack/pen QL

DispensingPack-size limits specified in Limits & Restrictions

RYBELSUS — 1 tablet per day

RYBELSUS (oral semaglutide)1 tablet per day

Limit typeDaily tablet limit

ContextListed with QL/pack limits in diabetes/incretin section

SGLT2 and combination agents — documented daily tablet limits

SGLT2 / combination agents (examples)Documented daily tablet limits (e.g., 1 tab/day or 2 tabs/day depending on product)

ProductsIncludes SYNJARDY, TRIJARDY and related combinations with daily tab limits

FlaggingListed with QL PA in many entries

ondansetron (multiple formulations) — managed via OH OncoHealth

Ondansetron formulationsManaged via OH OncoHealth (oncology program) — OncoHealth routing indicated

Numerical QLNo explicit numeric QL shown in extract; managed under oncology benefit

ImplicationPrior authorization / oncology program routing applies

naftifine hcl 2% cream — 60 GM

Naftifine HCl 2% cream60 GM per 30 days

Econazole nitrate 1% cream85 GM per 30 days

Nystatin suspension480 mL per prescription

econazole nitrate 1% cream — 85 GM

Econazole nitrate 1% cream85 GM

Nystatin suspension480 ML per RX

Tranexamic acid 650 mg tablet30 tabs per RX

nystatin (suspension) — 480 ML

Nystatin (oral suspension)480 ML per prescription

ContextListed with QL and PA flags in antifungal/topical sections

UnitmL per RX

tranexamic acid 650 mg tablet — 30 tabs

Tranexamic acid 650 mg tablet30 tabs per prescription

Therapeutic areaListed among hemostatic/coagulation supportive agents

Unittabs per RX

BAQSIMI — 4 vials

BAQSIMI (glucagon)4 vials per prescription

Limit typeQuantity limit (QL) applied to emergency glucagon kits

Unitvials per RX

REPATHA PUSHTRONEX — QL 1 PEN ST

REPATHA PushtronexQL 1 PEN per starter (ST)

REPATHA SureClickQL 2 PENS per starter (ST)

EMGALITY 120 mg/mL (syringe/pen)1 mL per 28 days

REPATHA SURECLICK — QL 2 PENS ST

REPATHA SURECLICKQL 2 PENS per starter (ST)

REPATHA SYRINGEQL 2 PENS ST (as listed)

ContextPCSK9 inhibitors listed with QL and starter pack constraints

EMGALITY 120 MG/ML — 1 ML 28 DAYS

EMGALITY 120 mg/mL (syringe/pen)1 mL per 28 days

Pack/pen limitsListed with QL PA in specialty biologic section

UnitmL per 28 days

NURTEC ODT — 8 TABS 30 DAYS

NURTEC ODT8 TABS per 30 days

REYVOW8 TABS per 30 days

Zolmitriptan ODT / ZOMIG12 TABS per 28-30 days

REYVOW — 8 TABS 30 DAYS

REYVOW8 TABS per 30 days

NURTEC ODT8 TABS per 30 days

ZOLMITRIPTAN ODT / ZOMIG12 TABS per 28-30 days

ZOLMITRIPTAN ODT / ZOMIG — 12 TABS 28-30 DAYS

Zolmitriptan ODT / ZOMIG12 TABS per 28-30 days

ClassificationListed with QL in migraine therapy section

Unittabs per 28-30 days

Cyclophosphamide 50 mg capsule (brand) — referenced quantity limits

Cyclophosphamide 50 mg capsule (brand) — multiple entriesDocumented quantity phrasing includes '3 CAPS 1 DAY' and 'CAPS 1 DAY' across listings

Utilization flagsEntries show QL, PA, TD and OncoHealth/ONC routing flags

TierAssigned to oncology specialty listings (Tier 4 noted elsewhere)

Cyclophosphamide 50 mg capsule (brand) — CAPS 1 DAY / CAPS 1

Cyclophosphamide 50 mg capsule (brand) — phrasingCAPS 1 DAY / CAPS 1 seen in limits & restrictions entries

Daily cap3 (capsules) referenced in multiple places

Program routingListed under OncoHealth/ONC specialty benefit

Cyclophosphamide 50 mg capsule (brand) — 3 capsules

Cyclophosphamide 50 mg capsule (brand)3 capsules (phrasing '3 CAPS 1 DAY')

ContextAppears with QL PA TD and OncoHealth flags

NoteExact clinical criteria not present in fragment

Cyclophosphamide 50 mg capsule (brand) — CAPS 1 DAY; 3 CAPS 1 DAY phrasing

Cyclophosphamide 50 mg capsule (brand)Documented phrasing: 'CAPS 1 DAY' and '3 CAPS 1 DAY' repeated

ImplicationDaily capsule descriptors used across OncoHealth listings

Associated flagsQL, PA, TD, ONC/OH present in listing

Cyclophosphamide 50 mg capsule (brand) — 3 CAPS 1 DAY / CAPS 1 DAY

Cyclophosphamide 50 mg capsule (brand)3 CAPS 1 DAY / CAPS 1 DAY phrasing appears repeatedly

UsageUsed in oncology specialty OncoHealth entries with QL/PA flags

TierListed in oncology specialty section

CYCLOPHOSPHAMIDE 50 MG CAPSULE (BRAND) — 3 caps 1 day

CYCLOPHOSPHAMIDE 50 MG CAPSULE (BRAND)Referenced as '3 caps 1 day' and 'CAPS 1 DAY' in Limits & Restrictions

Program routingOncoHealth / ONC specialty designation evident in fragment

AuthorizationPA and QL flags accompany entries

IMBRUVICA 420 MG TABLET — 1 TAB

IMBRUVICA 420 mg tablet1 TAB (per day listed)

Authorization flagsListed with QL PA S OH in oncology listings

ContextOncology specialty routing noted in entry

IMBRUVICA 70 MG/ML SUSPENSION — 6 ML

IMBRUVICA 70 mg/mL suspension6 mL per day

Limit typeSpecified daily volume for suspension formulation

FlagsListed with QL PA S in oncology specialty entries

KISQALI dosing forms — 63 TABS

KISQALI dosing forms63 TABS (commonly referenced for certain dosing/pack configurations)

Alternate21 TABS per 28 days noted for 200 mg daily dose

ContextUsed in OncoHealth/ONC oral oncology supply formatting

Cyclophosphamide examples — 3 CAPS or 1 DAY phrasing

Cyclophosphamide examplesEntries use '3 CAPS' or '1 DAY' phrasing across listings

InterpretationRepresents repeated per-day capsule descriptors within oncology section

ActionFollow Limits & Restrictions and PA/QL requirements when submitting requests