HSA Plus 2026 Formulary (Drug List)
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This document is the HealthPartners HSA Plus 2026 formulary listing covered medications, tier assignments, and special program flags (e.g., PA, ST, QL) that govern pharmacy coverage and prior authorization/limit requirements for members and providers.
No material clinical or coverage changes in this revision.
Coverage and Table Controls
Coverage determined by table entries
Coverage and utilization controls are determined by each formulary table row. The product's tier and any listed Requirements / Limits (for example PA, OP, QL, S) must be satisfied for coverage.
Follow the specific product row in the formulary table for exact authorization, specialty, and quantity rules.
General coverage controls (table-level)
Coverage and utilization management is product- and formulation-specific as indicated in the table; common controls include:
Refer to the individual line item for the exact tier, PA, S and QL values on the formulary table.
Providers should include diagnosis, previous therapies tried, and other supporting documentation when requesting PA or QL overrides.
Exact QL values are shown on each formulation line in the table and govern dispensing and approvals.
Certain product lines in the formulary excerpt are designated NF (Non‑Formulary) and, where shown, are paired with utilization controls such as PA (prior authorization) or numeric QL (quantity limits). Examples in this fragment include ANCOBON (listed as NF; PA) and several antifungal liquid or specialty formulations (e.g., itraconazole solution, SPORANOX 100 mg, VFEND oral suspension) that are flagged NF and require PA per the table entries. These NF designations imply restricted coverage unless the listed requirements/limits are satisfied.
Within the provided excerpts there are no standalone clinical exclusion statements tied to diagnoses or patient populations; instead the table uses formulary flags such as NF and constraint codes (for example PA, OP, and explicit QL values) to indicate where coverage is limited or controlled. The presence of NF entries in the drug rows therefore functions as an operational restriction rather than an explicit clinical exclusion in these fragments.
The excerpt does not include any discrete 'not medically necessary' condition lists. Coverage limitations in these fragments are expressed through formulary status and utilization codes (e.g., NF, PA, QL), not by enumerating procedures or diagnoses considered not medically necessary.
Formulary Entries and Code Tables
| METADATE CD ORAL CAPSULE | ER BIPHASIC 30-70 10 MG, 20 MG, 30 MG — Drug Tier = NF; Requirements / Limits = PA; QL (2 per 1 day) |
| METADATE CD ORAL CAPSULE | ER BIPHASIC 30-70 40 MG, 50 MG, 60 MG — Drug Tier = NF; Requirements / Limits = PA; QL (1 per 1 day) |
| methylphenidate hcl oral capsule, er biphasic 30-70 | 10 mg, 20 mg, 30 mg — Drug Tier = 3; Requirements / Limits = QL (2 per 1 day) |
| methylphenidate hcl oral capsule, er biphasic 30-70 | 40 mg, 50 mg, 60 mg — Drug Tier = 3; Requirements / Limits = QL (1 per 1 day) |
| ELIQUIS ORAL TABLET 5 MG | Drug Tier = 3; Requirements / Limits = QL (74 per 30 days) |
| ELIQUIS ORAL TABLET 2.5 MG | Drug Tier = 3; Requirements / Limits = QL (2 per 1 day) |
| ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS) | Requirements / Limits = QL (74 per 30 days) |
| ELOCTATE INTRAVENOUS RECON SOLN | Available units: 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT — Drug Tier = 6; Requirements / Limits = PA; S |
| ADVATE INTRAVENOUS RECON SOLN | Units include 250, 500, 1,000, 1,500, 2,000, 3,000, 4,000 UNIT — Requirements / Limits = PA; S |
| ALPHANATE INTRAVENOUS RECON SOLN | 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML — Requirements / Limits = PA; S |
| HEMLIBRA SUBCUTANEOUS SOLUTION | Strengths: 105 MG/0.7 ML, 12 MG/0.4 ML, 150 MG/ML, 30 MG/ML, 300 MG/2 ML (150 MG/ML), 60 MG/0.4 ML — Drug Tier = 6; Requirements / Limits = PA; S |
| FRAGMIN SUBCUTANEOUS SYRINGE | Multiple anti-Xa unit strengths — Requirements / Limits = QL (varies) |
| JIVI INTRAVENOUS RECON SOLN | Units: 1,000, 2,000, 3,000, 4,000, 500 UNIT — Requirements / Limits = PA; S |
| ARIXTRA SUBCUTANEOUS SYRINGE | Multiple strengths with QL (12-24 per 30 days depending on strength) |
| ELIQUIS DVT-PE TREAT 30D START | QL (74 per 30 days) |
| PA | Prior Authorization required (examples: METADATE CD, ELOCTATE, HEMLIBRA) |
| QL | Quantity limit applied (examples: METADATE CD, ELIQUIS, ARIXTRA) |
| S | Specialty distribution (examples: ELOCTATE, HEMLIBRA) |
| NF | Non-formulary tier designation (examples: METADATE CD entries listed as NF for certain strengths) |
| METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 | 10 MG, 20 MG, 30 MG — NF; PA; QL (2 per 1 day) |
| METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 | 40 MG, 50 MG, 60 MG — NF; PA; QL (1 per 1 day) |
Prior Authorization, Step Therapy, Documentation and Risks
Prior Authorization Required
Prior authorization (PA) is commonly required across the drug list. When a product is marked with PA (or with combined flags such as PA; S; ONC; TD) providers must request prior authorization before the plan will cover the medicine. Failure to obtain required PA may result in denial or non-coverage.
- PA = Prior Authorization Required
- Many oncology and specialty agents are additionally flagged ONC, S and/or TD and require PA to establish medical necessity
- PA-marked oral antiviral and anti-infective formulations (e.g., PAXLOVID, PREVYMIS) may also have quantity limits (QL) and require PA
PA, Specialty and Quantity‑Limit Combinations
Some medicines on the list combine multiple program flags (PA; QL; S; ONC; TD). These combinations indicate the product is managed under specialty or oncology programs and that both PA and adherence to quantity limits must be met. Examples include numerous oral oncology agents and specialty injectables.
- PA + ONC + S + QL examples: BOSULIF, CALQUENCE, everolimus (antineoplastic)
- PA + S examples: many specialty injectables and high‑cost oral specialty products (see oncology/specialty clusters)
- PA + QL examples: many antiviral/antibiotic oral formulations (e.g., PAXLOVID QL per day limits)
Step Therapy Requirement
Step therapy (ST) applies for medicines where the plan requires trials of one or more alternatives before covering the requested product. Items marked ST must follow the plan’s step‑therapy sequencing and require provider attestation or prior approval if steps have not been met.
- ST = Step Therapy Required
- Examples where ST is shown in the table: TRINTELLIX (ST), zolpidem XR (ST)
- Products marked S may also be managed through specialty programs that include step requirements
Quantity Limit Documentation and Overrides
Quantity limits (QL) are enforced per fill or per time period. Requests that exceed the listed QL are subject to medical necessity review and may be denied if supporting documentation is not provided.
- QL examples: PAXLOVID (QL per 1 day), ARIKAYCE (QL per 30 days), numerous antiseizure and migraine products have QLs
- Exceeding QL may trigger a PA review and possible denial
- When requesting QL overrides include diagnosis, prior therapies tried, and prior use within QL
Specialty Injectable Products — PA and Site‑of‑Care Considerations
Specialty injectables and high‑cost infusion products commonly carry PA and S flags and may require site‑of‑care or infusion‑specific handling. Providers should obtain PA and include documentation to meet specialty program requirements to avoid coverage delays.
- Examples: many injectable biologics and clotting‑factor products marked PA; S (e.g., BENEFIX, ELOCTATE, HEMLIBRA)
- Infusion or specialty pharmacy management may be required for PA approval
Supporting Clinical Documentation Required for PA / QL / Specialty (S) Items
Documentation expectations: PA requests and quantity‑limit override requests must include product name/strength, requested quantity, diagnosis, dosing details, prior treatment history (including dates and outcomes), and any relevant clinical test results. For products with combined flags (PA; S; QL) include specialty‑program documentation as indicated.
- Required claim details: product, strength, quantity and dosing must match the formulary entry
- Supporting documentation: diagnosis, prior use of requested product within QL, alternatives tried, and clinical rationale
- For PA+S items, include specialty pharmacy enrollment or justification as required
Policy Background and Rationale
Specialty medications in the formulary are managed differently from routine retail drugs: they are typically high‑cost, used for chronic or complex diseases, and require additional handling. The table indicates that specialty medicines must be filled at a specialty pharmacy, and products marked with specialty/site flags (for example S or ONC) may require dispensing or administration through a specialty pharmacy or infusion center per the payer rules.
Abbreviations and Program Flags
Step Therapy Indicators and Applications
| Drug list flag | Meaning / Plan action |
|---|---|
| ST | |
| Indicates step therapy applies; member must try required first-line medication(s) before the listed product will be covered at the lowest copay/coinsurance. Provider must obtain approval if steps not met. |
| Table annotation | Implication for coverage |
|---|---|
| PA; S | |
| Product requires prior authorization (PA) and is managed as a specialty item (S); supporting documentation and specialty pharmacy/site requirements apply before coverage. |
| Program flags | Management pathway |
|---|---|
| ONC / TD / S | |
| Oncology (ONC), trial/ treatment designation (TD), and specialty (S) flags denote oncology/specialty pathway management; PA, QL and specialty handling commonly apply. |
| Example product | Table notation / action |
|---|---|
| Carbidopa-levodopa extended release | |
| Listed in formulary lines; some extended-release carbidopa-levodopa products are marked 'ST', indicating step therapy applies per table notation. |
| Product | Requirements / Limits |
|---|---|
| INGREZZA initiation pack | |
| Requirements / Limits = PA; S; QL (28 per 273 days) — initiation pack and other INGREZZA listings show 'S' indicating specialty/step-related controls and prior authorization. |
| Observation | Explanation |
|---|---|
| No explicit multi-step sequences provided | |
| The formulary table uses 'ST' where step therapy applies, but detailed multi-step sequencing is not listed in the provided excerpts; many products instead show PA and QL controls. |
| Product / flag | Action / note |
|---|---|
| GEODON (as listed) | |
| Includes 'AL (Min 7 Years)' age-limit flag in Requirements / Limits — indicates age-based authorization criteria apply (AL). |
| Product | Table notation |
|---|---|
| TRINTELLIX oral tablet | |
| Requirements / Limits = ST; QL (1 per 1 day) — Trintellix is specifically marked 'ST' indicating step therapy applies for this agent. |
| Product | Formulary flags |
|---|---|
| Zolpidem oral tablet, extended-release multiphase | |
| Requirements / Limits = ST; QL (1 per 1 day) — listed with 'ST', indicating step therapy requirement for this extended-release zolpidem formulation. |
| Product group / example | Table annotations / coverage impact |
|---|---|
| Oral anticoagulant formulations (examples: ELIQUIS, XARELTO) | |
| Selected formulations show QL and some show PA (e.g., ELIQUIS QL entries; XARELTO examples) — PA plus QL or specialty flags on oral anticoagulants indicate additional management and possible step/coverage checks per table entries. |
Quantity Limits by Product
Specialty Pharmacy and Infusion Requirements
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