Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHealthPartners HSA Plus Formulary Coverage Update …
    Ask Trek AI about this page

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentHealthPartnersPolicy N/A

    HSA Plus 2026 Formulary (Drug List) — Pharmacy Coverage Criteria

    Customize your policy alerts

    Sign up for all HealthPartners policy alerts

    Know when HealthPartners releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Lists medicines covered by the HSA Plus pharmacy benefit, defines tiers and program flags (PA, ST, QL, AL, ONC, OP, ACA, TD, S), and provides drug-specific tier and utilization controls relevant to HealthPartners members and providers.

    Policy Summary
    PayerHealthPartners
    PolicyHSA Plus 2026 Formulary (Drug List) — Pharmacy Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes (routine review)
    Effective DateFeb 1, 2026
    Next Review DateN/A
    Key ActionSubmit Prior Authorization (PA) when a drug line indicates 'PA' to avoid claim denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7Formulary tiers defined
    manyEntries with PA
    severalEntries with QL
    ~120Distinct drug entries
    specialty pharmacySpecialty handling note
    NCApplicable state

    Formulary Coverage Conditions & Per-Product Controls

    Coverage conditions and program rules

    Formulary coverage is subject to program flags and criteria; coverage requires meeting PA, ST, QL, AL, ONC, OP, ACA, or TD rules as specified.

    Prior Authorization: When a drug is marked PA, it is covered only if HealthPartners prior authorization criteria are met.

    See drug-specific entries for PA; failure to obtain PA may result in non-coverage.

    Step Therapy: When a drug is marked ST, the member must have tried specified alternative agent(s) prior to coverage of the requested drug unless an exception is approved.

    Coverage at the lowest copay/coinsurance requires step completion or approval.

    Quantity Limits: When a drug has a QL, fills above the limit require medical necessity review including diagnosis and prior therapy information.

    Requests above QL will be reviewed for medical necessity and must include diagnosis, alternatives tried, prior use and evidence of efficacy/safety.

    Policy Summary
    PayerHealthPartners
    PolicyHSA Plus 2026 Formulary (Drug List) — Pharmacy Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes (routine review)
    Effective DateFeb 1, 2026
    Next Review DateN/A
    Key ActionSubmit Prior Authorization (PA) when a drug line indicates 'PA' to avoid claim denial.
    SourceLink
    On This Page
    Formulary Coverage Conditions & Per-Product ControlsFormulary Listings & Sample Code/ItemsPrior Authorization, Step Therapy, Documentation & Denial RiskFormulary Symbols, Tiers & Program FlagsStep Therapy Indicators & Affected ProductsPer-Product Quantity Limits (QL) — Examples & ValuesSpecialty Pharmacy, Infusion & Outpatient HandlingFormulary Context & Specialty Medicine Notes
    Trial Drug Program: Some new drugs are in the Trial Drug Program with the first 6 fills potentially limited; subsequent fills may provide the rest of the month supply if tolerated.6 fills

    If a copay applies, the member pays no more than one copay per month supply during the trial.

    Oncology / Specialty Flags: When ONC, TD, or S flags appear, oncology or specialty program requirements apply in addition to PA/QL as indicated.

    Examples: many oral oncology agents listed with PA; ONC; TD; S (see product lines).

    Per-product coverage controls

    Coverage for each listed drug is subject to the product-level requirements shown on the formulary line.

    Formulary product requirements: Coverage for each listed drug is subject to the requirements shown next to the drug (e.g., PA, ONC, S, TD, QL). When multiple flags appear, all specified controls apply.

    Extract individual controls from the product line (examples in chunks 72–73).

    Per-product formulary coverage and restrictions

    Coverage and restrictions are specified per drug formulation in the listing. Each line shows Drug Tier and Requirements / Limits (PA, QL, S, ST, OP, ACA, TD, ONC).

    Per-line coverage rules: Each listed product is assigned a formulary tier and may require prior authorization (PA), have quantity limits (QL), step therapy (ST/S), or specialty/site flags (S, ONC, OP, ACA, TD) as shown in the Requirements / Limits column.

    Providers must consult the specific product line in the table for the applicable PA/QL/S/ST flags (examples: XCOPRI titration pack PA; QL (1 per 1 day); many antiepileptic agents with PA/QL).

    Formulary coverage entries

    Formulary coverage entries provide the actionable utilization controls by drug formulation (tier plus Requirements / Limits).

    Formulary entry: Each product line includes a Drug Tier and may include Requirements / Limits such as PA (prior authorization), QL (quantity limits), OP (outpatient/site restriction), ST/S (step therapy), ONC (oncology program), ACA, or TD.

    Examples in this segment include NUCYNTA (PA; QL per day), TRAMADOL entries (PA; QL per day), SUBOXONE (PA; QL), and many specialty oncology agents with PA; ONC; S flags.

    When a product is marked PA in the formulary, coverage is conditional on obtaining HealthPartners prior authorization. Failure to obtain required prior authorization may result in the drug not being covered for the member.

    The provided formulary excerpt does not include an explicit list of medications designated as excluded for medical necessity reasons; instead, entries show product-level administrative controls such as PA and QL. No lines in the excerpt are labeled as 'Not Medically Necessary' or similarly worded.

    Coverage for individual products is controlled by the program flags shown on each product line — principally PA (prior authorization) and QL (quantity limits). Products that do not display an explicit PA or QL flag in the excerpt may still be subject to other formulary controls or program requirements described elsewhere in the full formulary.

    This excerpt does not present a 'Not Covered' list; instead it implements utilization controls (e.g., PA, QL, OP/site flags) on product lines to govern coverage and dispensing.

    Within the provided excerpt there are no entries explicitly labeled as 'not medically necessary.' Coverage determinations in the excerpt are conveyed through PA/QL and other program flags rather than NMN statements.

    Formulary Listings & Sample Code/Items

    Anticoagulants / LMWHmixed
    LOVENOX 300 MG/3 MLLOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML — Drug Tier = NF; Requirements / Limits = QL (6 per 1 day).
    LOVENOX SUBCUTANEOUS SYRINGE 100 MG/MLLOVENOX SUBCUTANEOUS SYRINGE 100 MG/ML — Drug Tier = NF; Requirements / Limits = QL (6 per 1 day).
    LOVENOX SUBCUTANEOUS SYRINGE 150 MG/MLLOVENOX SUBCUTANEOUS SYRINGE 150 MG/ML — Drug Tier = NF; Requirements / Limits = QL (6 per 1 day).
    Direct Thrombin Inhibitorsmixed
    PRADAXA ORAL CAPSULE 75 MGPRADAXA ORAL PELLETS/ CAPSULE 75 MG — Drug Tier = NF; Requirements / Limits = PA; QL (4 per 1 day) when listed as pellets or per formulation where applicable.
    PRADAXA ORAL CAPSULE 110 MGPRADAXA ORAL PELLETS IN PACKET 110 MG — Drug Tier = NF; Requirements / Limits = PA; QL (4 per 1 day).
    PRADAXA ORAL CAPSULE 150 MGPRADAXA ORAL PELLETS IN PACKET 150 MG — Drug Tier = NF; Requirements / Limits = PA; QL (2 per 1 day).
    COVID-19 Oral Antiviralsmixed
    PAXLOVID ORAL TABLETS, DOSE PACKPAXLOVID ORAL TABLETS, DOSE PACK — Requirements / Limits = QL (4 per 1 day) for certain pack configurations; other pack QL shown as applicable.
    LAGEVRIO (molnupiravir) - exampleLAGEVRIO / oseltamivir entries are shown elsewhere in the table; QL examples included in abbreviations list.
    Formulary items (sample)mixed
    Example DrugPlaceholder — no billing codes in excerpt.
    Listed drug names & strengths (placeholder)mixed
    SampleListed names and strengths placeholder.
    Section header (coding table placeholder)mixed
    HEADERCoding table placeholder entry.
    Selected drug line items with QLmixed
    LOVENOX 300 MG/3 MLLOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML — Requirements / Limits = QL (6 per 1 day).
    PRADAXA ORAL CAPSULE 110 MGPRADAXA ORAL PELLETS IN PACKET 110 MG — Requirements / Limits = PA; QL (4 per 1 day).
    PRADAXA ORAL CAPSULE 150 MGPRADAXA ORAL PELLETS IN PACKET 150 MG — Requirements / Limits = PA; QL (2 per 1 day).
    PA + QL examplesmixed
    PRADAXA 110 MGPA; QL (4 per 1 day).
    PRADAXA 150 MGPA; QL (2 per 1 day).
    PCSK9 inhibitors (sample)mixed
    REPATHA PUSHTRONEX 420 MG/3.5 MLRequirements / Limits = ST; QL (3.5 per 28 days).
    REPATHA SURECLICK 140 MG/MLRequirements / Limits = ST; QL (2 per 28 days).
    inv-19: Trial Drug Program initial fills — first 6 fills may be limited; render as a compact key/value.
    Trial Drug Program initial fillsFirst 6 fills of a trial drug may be limited to less than a month supply; if medicine tolerated, remainder of month supplied; if copay applies, max one copay per one month supply.
    inv-20: Nystatin QL example (480 per 30 days).
    Nystatin QL exampleQL (480 per 30 days) for nystatin oral suspension 100,000 unit/ml.
    inv-21: Edurant PED QL (6 per 1 day).
    Edurant PED QLQL (6 per 1 day) for EDURANT PED ORAL TABLET FOR SUSPENSION 2.5 MG.
    inv-22: Quantity limits examples (PAXLOVID, LAGEVRIO, oseltamivir).
    COVID-19 oral antivirals QL examplesPAXLOVID QL (4 per 1 day for certain packs; 6 per 1 day for others).
    inv-23: Examples of QL thresholds present in table (various QL patterns).
    Various QL thresholdsExamples across the formulary include per-day and per-30-day quantity limits (e.g., 1 per day, 3 per 1 day, 148 per 30 days).
    inv-26: LOVENOX QL examples (multiple syringe/pack sizes).
    LOVENOX QL examplesLOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML — QL (6 per 1 day).
    inv-27: PRADAXA QL example (2 per 1 day).
    PRADAXA QL examplePRADAXA ORAL PELLETS IN PACKET 110 MG — QL (4 per 1 day); PRADAXA 150 MG — QL (2 per 1 day).
    inv-28: REPATHA QL examples (2 per 28 days; 3.5 per 28 days).
    REPATHA QL examplesREPATHA PUSHTRONEX 420 MG/3.5 ML — QL (3.5 per 28 days); REPATHA SURECLICK/SYRINGE 140 MG — QL (2 per 28 days).

    Prior Authorization, Step Therapy, Documentation & Denial Risk

    Prior Authorization

    Prior Authorization Required

    Prior authorization (PA) is required for many drugs listed in the formulary. Providers must obtain approval from HealthPartners before these medicines will be covered by the pharmacy benefit; failure to obtain PA may result in the drug not being covered or claims denied.

    • Applies broadly across formularies — oral, inhaled, injectable and specialty agents.
    • PA indicators shown in the formulary Requirements / Limits column (marked 'PA').
    • Coverage may depend on meeting HealthPartners clinical criteria.
    Prior Authorization

    PA required for specialty / oncology drugs

    Many specialty and oncology drugs are designated PA and often carry additional program flags (ONC, S, TD). These products commonly require enrollment in specialty or oncology programs and submission of specific documentation to support medical necessity.

    • ONC = oncology benefit flag; S = specialty; TD = trial drug — see formulary legend for definitions.
    • Examples: multiple antineoplastic/immunosuppressant oral and injectable agents are marked with PA; ONC; S and often have QL.
    • Provider should confirm program enrollment and required documentation before submitting PA requests.
    Documentation Required

    PA and QL for starter kits

    Prior authorization and quantity limits (QL) apply to starter kits and dose packs. Requests exceeding QL will be reviewed for medical necessity; prescribers must document indication, dosing, prior therapies tried, and rationale for quantities above the limit.

    • Starter kits / dose packs (e.g., VENCLEXTA starting pack, ZEPOSIA starter kits) are frequently marked PA; S and include QL.
    • Dose-pack QLs are expressed as counts per timeframe (for example, 28 per 180 days).
    • Documentation should include dosing schedule, diagnosis, prior agent trials, and clinical rationale for override requests.
    Prior Authorization

    PA required for many antiepileptic agents

    Many antiepileptic agents and other neurologic therapies require prior authorization and may have quantity limits. Providers must obtain PA prior to dispensing to avoid denial risk.

    • Examples include KEPPRA, VIMPAT, XCOPRI, ZARONTIN and other anticonvulsants marked 'PA' or 'PA; QL'.
    • Some extended‑release or titration packs are subject to PA and separate QLs.
    • Check the Requirements / Limits column for PA and specific QL values.
    Step Therapy

    Prior Authorization and Step Therapy Requirements

    Step therapy (ST) and step edits are applied where indicated. When a product is marked ST or S, earlier‑line therapy may be required before coverage of the requested agent. Exceptions may be granted with clinical justification through PA.

    • ST means the member must try specified first‑line agents before the stepped‑to drug.
    • Products marked 'S' indicate step/program flags — review formulary legend and Requirements / Limits for details.
    • Providers should document prior therapies tried, response, and reason for failure when submitting PA as exception to step therapy.
    Denial Risk

    Documentation, Quantity Limits & Denial Risk

    Quantity limits (QL), program flags (S, ONC, TD), and PA together drive coverage and documentation requirements. Claims may be denied without PA or when QLs are exceeded — providers must supply dosing, indication, prior treatments, and evidence of necessity.

    • QLs are shown as numeric limits with timeframes (e.g., '2 per 1 day', '28 per 180 days').
    • Program flags (ONC, S, TD) imply supplemental requirements — consult the formulary legend.
    • Requests above QL will be reviewed for medical necessity and require documentation of diagnosis, alternatives tried, and prior use.

    Formulary Symbols, Tiers & Program Flags

    Specialty Medicine definition
    DefinitionSpecialty medicines: high‑cost, require more management, often must be filled at a specialty pharmacy and may be covered under a different benefit
    Site of fillPrescriptions for specialty medicines must be filled at a specialty pharmacy (see member plan benefits)
    Program flagsProducts marked 'S' indicate specialty handling or routing in the Requirements / Limits column
    Tier (formulary tiers) explanation
    PurposeTier indicates member cost‑sharing level for a medicine
    Tier listTier 1 = Preventive Generics; Tier 2 = Preventive Brands; Tier 3 = Formulary Generics & Preferred Brands; Tier 4 = Formulary Non‑Preferred; Tier 5 = Specialty Generics; Tier 6 = Specialty Brands; Tier 7 = Oral Chemotherapy
    Non‑FormularyNF indicates Non‑Formulary
    Requirement symbols (PA, QL, S, ACA, AL, etc.)
    PAPrior Authorization required
    QLQuantity Limit — maximum allowed amount in specified time frame
    S / ST / TD / OP / ACA / ALS = Specialty; ST = Step Therapy; TD = Trial Drug Program; OP = Opioid Program; ACA / ACA‑PA = Affordable Care Act designations; AL = Age Limit
    Prior Authorization (PA) definition
    DefinitionPrior Authorization (PA): plan requires approval before dispensing; failure to obtain PA may result in the drug not being covered
    Provider actionProviders must submit required documentation to support PA per product-specific criteria
    Table usagePA is shown in the Requirements / Limits column for each product line — consult that line for PA applicability
    Oncology (ONC), TD and Specialty (S) flags
    ONC flagONC indicates the Oncology Benefit — agent managed under oncology program
    TDTD indicates Trial Drug Program controls apply (e.g., initial limited fills)
    SS indicates specialty routing/handling is required
    PA (alternate reference)
    PA (short)Prior Authorization — approval required before coverage
    ImplicationClaims submitted without PA when PA is required may be denied
    Where shownShown in Requirements / Limits column next to product line
    ONC (oncology program) definition
    ONC programOncology program requirement — many oncology agents are managed under ONC with PA and specialty routing
    Document requirementsONC entries often include TD and S flags and may have QL; follow oncology program procedures for authorization
    QL (Quantity Limit) definition
    QLQuantity Limit — maximum allowed quantity in specified timeframe (e.g., QL (21 per 28 days))
    ExamplesShown per product line (per day, per 28 days, per 30 days) — e.g., BRIVIACT QL (10 per 1 day)
    ACA‑PA designation explanation
    ACA‑PAACA‑PA = Affordable Care Act designation that may require PA for ACA‑covered products
    UseIndicates products covered under ACA with a PA requirement where applicable
    Quantity Limit (QL) shorthand
    QL (shorthand)QL = Quantity Limit — maximum units allowed per specified period
    How shownExpressed as QL (X per Y days) on product line
    Prior Authorization label (alternate)
    Prior Authorization labelPA denotes prior authorization required before coverage
    ConsequenceLack of PA may result in non‑coverage or claim denial
    Oncology indicator (ONC) shorthand
    ONC shorthandONC shown next to many antineoplastics indicating oncology benefit management
    Associated flagsOften appears with PA, TD, S and QL entries
    TD (time or dose / Trial Drug Program) indicator
    TDTD = Trial Drug Program (initial limited fills for first 6 fills)
    EffectFirst 6 fills may be limited to less than a month supply; subsequent fills may provide full month if tolerated
    S — specialty pharmacy / handling indicator
    SS = Specialty — indicates specialty pharmacy handling or special services required
    Operational noteSpecialty products often must be filled at a specialty pharmacy and may be on a separate benefit
    PA definition (another chunk)
    PA (restated)Prior Authorization — administrative approval required before coverage
    Where to checkShown in Requirements / Limits column for each product line
    QL definition (another chunk)
    QL (restated)Quantity Limit — maximum units allowed in specified timeframe (e.g., per day, per 28 days, per 30 days)
    Provider actionRequests above QL require documentation and medical necessity review
    Drug Tier definition
    Drug TierFormulary tier assigned to product determines member cost sharing (Tiers 1–7; NF = non‑formulary)
    Where shownDisplayed in the Drug Tier column for each product line
    PA (duplicate definition)
    PA summaryPA = prior authorization required — plan requires approval before dispensing
    DocumentationProviders must supply supporting documentation when submitting PA requests
    QL (duplicate definition)
    QL (duplicate)Quantity Limit — maximum allowable quantity per time period as indicated on product line
    ExamplesShown as per day/per 28 days/per 30 days values (e.g., 1 per 1 day; 48 per 30 days)
    S — step edit / special prior‑step requirement
    S (step edit)S may indicate a step edit or special prior‑step requirement per formulary legend
    ImplicationProducts with 'S' may require trying earlier‑line therapy before approval
    OP — Opioid program flag
    OPOP = Opioid Program flag — indicates special program requirements for opioid products
    EffectOP appears with certain opioid products and may change authorization or quantity rules
    QL (definition duplicate)
    QL (duplicate)Quantity Limit — maximum allowed units in specified timeframe
    Use in tableExpressed as QL (X per Y days) in Requirements / Limits column
    PA (definition duplicate)
    PA (duplicate)Prior Authorization — approval required before coverage; absence of PA may result in noncoverage
    Provider stepSubmit PA per product-specific criteria in the formulary
    Abbreviations used in table (summary)
    Legend abbreviationsPA = prior authorization; QL = quantity limit; OP = outpatient/opioid program; ACA = Affordable Care Act designation
    Where definedAbbreviations are explained at the beginning/list legend of the formulary table
    PA (duplicate)
    PA (repeat)Prior Authorization — authorization required prior to coverage
    ConsequenceClaims may be denied without PA when PA is indicated
    QL (duplicate)
    QL (repeat)Quantity Limit — maximum units per timeframe shown (e.g., 8 per 1 day; 2 per 30 days)
    EnforcementRequests above QL require medical necessity documentation
    S — Specialty medication designation
    S (specialty)S = Specialty medication designation — implies specialty pharmacy handling or special services
    ExamplesAppears for many injectables/biologics (e.g., HEMLIBRA, ADVATE) and high‑tier specialty products
    NF — non‑formulary explanation
    NFNF = Non‑Formulary
    ImplicationNF entries may require PA or be non‑covered depending on plan and product
    PA (definition duplicate)
    PA (restated)Prior Authorization — plan requires approval before dispensing
    Provider actionObtain PA per product line to avoid denial
    QL (definition duplicate)
    QL (restated)Quantity Limit — maximum allowable quantity over specified period (e.g., per day, per 28/30 days)
    Product examplesMany products list QL values next to strengths/formulations
    S (definition duplicate)
    S meaningSpecialty — indicates specialty channel or handling required
    Operational noteProducts with S often have PA and QL and may be shipped via specialty pharmacy

    Step Therapy Indicators & Affected Products

    RuleWhat it means
    Member must try specified first-line agent(s) before coverage of the stepped-to drug
    If alternatives have not been tried, provider or member must obtain approval from HealthPartners before the medicine will be covered at the lowest copay/coinsurance
    NoteExplanation
    No explicit step therapy steps listed in this extract
    Formulary lines show flags (PA, QL, S, ST) but do not include step-by-step hierarchies in the cited chunks
    FlagImplication
    'S' flag present on many products
    Indicates a step edit or specialty/program requirement must be satisfied prior to coverage; exact step hierarchy not present in excerpt
    Product typeStep edit indication in table
    Extended‑release or specialty formulations (examples: gabapentin ER, pregabalin ER, lamotrigine XR)
    Listed with PA and/or QL and in some cases 'S' indicating step or program controls that must be met before coverage
    Example productsTable flags
    GOCOVRI (amantadine ER)
    Requirements / Limits = PA; S (step edit indicated)
    Starter kit / packRequirements
    ZEPOSIA starter kit (28‑day) and starter pack examples
    Requirements / Limits = PA; S; QL (starter kit QL example: 28 per 180 days) — starter kits/packs listed separately and require PA and may have distinct QL
    ObservationMeaning
    Many products include 'S' or other program flags
    Indicates additional step, specialty channel, or program requirements per formulary legend; providers should follow table legend and product line
    ProductStep therapy flag
    TRINTELLIX (vortioxetine) oral tablets
    Requirements / Limits = ST; QL (1 per 1 day) — TRINTELLIX is subject to step therapy (ST)
    FormulationStep indicator
    Zolpidem extended‑release multiphase tablets
    Requirements / Limits = ST; QL (1 per 1 day) — indicates 'ST' for some zolpidem ER entries
    AgentRequirements / Limits
    KESIMPTA (pen injector)
    Requirements / Limits = PA; S; QL (0.4 per 28 days) — 'S' (step/specialty) applies
    MAVENCLAD (oral tablet packs)
    Requirements / Limits = PA; S — 'S' applies for this specialty agent
    MAYZENT (oral tablets and starter packs)
    Requirements / Limits = PA; S; QL (examples: 4 per 1 day; starter kit limits shown) — step/specialty flags present
    PONVORY (starter pack and tablet)
    Requirements / Limits = PA; S; QL (1 per 1 day) — 'S' indicated
    ObservationComment
    Some branded or specialty oral therapies are marked PA
    Specific step edits are not detailed in the provided excerpt; product lines list PA and S flags which imply controls apply
    ProductStep therapy status
    REPATHA SURECLICK / SYRINGE / PUSHTRONEX
    Requirements / Limits = ST; QL (pens/syringes QL 2 per 28 days; Pushtronex QL 3.5 per 28 days) — REPATHA products require step therapy (ST) prior to coverage

    Per-Product Quantity Limits (QL) — Examples & Values

    Specialty Pharmacy, Infusion & Outpatient Handling

    Note
    Note
    Note
    Note

    Formulary Context & Specialty Medicine Notes

    Specialty medicines are typically high‑cost drugs used for chronic or complex conditions and often require additional management. The formulary notes these products may require specialty pharmacy handling or enrollment in specialty/oncology programs and are reviewed for safety, effectiveness and affordability by HealthPartners Pharmacy & Therapeutics.