HealthPartners HSA Plus Formulary Coverage & PA

Coverage and Utilization Criteria

Utilization Management Programs

Coverage and utilization management programs apply as described below.

Prior Authorization: Medication requires plan prior authorization before coverage

Providers must obtain PA to avoid denial of coverage (see PA policy)

Step Therapy: Some medicines require trial and failure or intolerance of specified alternative(s) prior to coverage of the requested agent

If alternatives have not been tried, provider must request approval

Quantity Limit: Quantity limits apply; requests above specified QL will be reviewed for medical necessityQL as specified per drug

Requests above QL require documentation of diagnosis, prior alternatives tried, prior use within limits, and evidence of efficacy/safety

Trial Drug Program: For certain new prescriptions a trial program may limit initial fills to less than a month supplyFirst 6 fills may be limited

If tolerated, subsequent fills will provide full month supply; copay rules apply per plan

Age Limit: Some medicines are covered only within specified age ranges; requests outside the age limit require prior approvalAL as specified per drug

Example: certain formulations have 'AL (Max 12 Years)'

Specialty / Site of Care: Certain oncology and specialty medicines are managed as specialty drugs and may require specialty dispensing or site restrictions

ONC and S flags indicate oncology or specialty handling; check member benefits for site-specific coverage

Formulary coverage conditioned on listed requirements

Coverage is conditioned on the Requirements / Limits specified for each drug entry.

General requirement: Drug is covered subject to the listed Requirements / Limits (for example: PA, QL, AL, ONC, S)

Providers must meet the specific prior authorization, quantity, age, oncology or specialty requirements shown on the product row

Formulary conditional coverage

Coverage and access for each listed product depend on product-specific flags; common flags include PA, ONC, S, TD, and QL.

Coverage flags: Products marked with PA require prior authorization; ONC indicates oncology-specific handling; S denotes specialty designation; QL indicates an explicit quantity limit; TD indicates Trial Drug Program

Interpret the Requirements / Limits column on each drug row to determine applicable administrative controls

Formulary coverage with utilization management

Coverage and utilization management are indicated per product row; coverage is conditional on meeting the listed Requirements / Limits.

Row-level coverage conditions: Coverage for each listed product requires adherence to its specific Requirements / Limits field (examples include PA, OP, QL, OP+PA combinations)

Products marked PA require prior authorization; products with QL must not exceed the stated quantity; OP indicates opioid program rules apply; failure to meet listed controls may result in denial

Some products are designated Non‑Formulary (NF) in the drug list and may also be annotated with utilization controls such as PA (prior authorization) and QL (quantity limits). Coverage for NF items depends on the member's plan benefits and on the outcome of any required prior authorization request; examples include ANCOBON (listed as NF; Requirements / Limits = PA) and VIVJOA (listed as NF; Requirements / Limits = PA; QL (18 per 84 days)). Providers should follow the formulary's Requirements / Limits for each product to determine whether PA or other documentation is needed before the plan will cover the medicine.

No explicit exclusions are stated in this portion of the formulary excerpt. The table rows shown identify drug tier and per‑product Requirements / Limits (for example, PA or QL) but do not provide standalone exclusion language in this segment.

This partial section presents product rows with coverage flags (PA, ONC, S, TD, QL) but does not include standalone exclusion statements. Interpret each drug row's Requirements / Limits to determine applicable coverage controls for the listed products.

The excerpted table rows do not include explicit clinical exclusions. Instead, entries show per‑product controls such as OP (opioid program), QL values, and PA indicators; any formal exclusions would be specified elsewhere in the full formulary documentation.

This segment does not list specific Not Medically Necessary conditions. The displayed information is limited to drug tiers and Requirements / Limits abbreviations (for example, PA, QL, AL, ONC, S); determinations of medical necessity are made through the plan's utilization review processes aligned with these flags.

Within the partial listing shown there are no explicit statements labeling any product as Not Medically Necessary. The rows instead annotate each product with tier and administrative controls (e.g., PA, QL, S), which drive coverage and review requirements.

This excerpt does not explicitly mark any product as Not Medically Necessary. Entries instead show formulary tiering and utilization controls (for example, opioid program flags OP, PA, and per‑day QL limits) that govern coverage and claim adjudication.

Drug Listings and Code Tables

Formulary entries (sample)mixed

ANCOBON ORAL CAPSULE 250 MG, 500 MG	NF; Requirements / Limits = PA
clotrimazole mucous membrane troche 10 mg	Tier 3
CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG	Tier 4; Requirements / Limits = PA
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml	Tier 3
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg	Tier 3
flucytosine oral capsule 250 mg, 500 mg	Tier 3; Requirements / Limits = PA
griseofulvin microsize oral suspension 125 mg/5 ml	Tier 3
itraconazole oral capsule 100 mg	Tier data incomplete

Selected drug entriesmixed

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG	Drug Tier = 7; Requirements / Limits = PA; ONC; S; QL (21 per 28 days)
KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)	Drug Tier = 7; Requirements / Limits = PA; ONC; S; QL (21 per 28 days)
LENVIMA	Example QL = 1 per 1 day (sample)
TOBI INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML	Drug Tier = NF; Requirements / Limits = PA; S; QL (5 per 1 day)
XENLETA ORAL TABLET 600 MG	Drug Tier = NF; Requirements / Limits = PA; QL (10 Per fill)
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML	Drug Tier = NF; Requirements / Limits = PA
nystatin oral suspension 100,000 unit/ml	Tier 3; Requirements / Limits = QL (480 Per fill)

Urinary tract & related agentsmixed

BLUJEPA ORAL TABLET 750 MG	Drug Tier = NF; Requirements / Limits = PA; QL (20 Per fill)
fosfomycin tromethamine oral packet 3 gram	Drug Tier = 4; Requirements / Limits = QL (3 Per fill)
methenamine hippurate oral tablet 1 gram	Drug Tier = 3
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg	Drug Tier = 3

Drug product list (formulations and strengths as listed)mixed

vancomycin oral capsule	125 mg, 250 mg
carbidopa-levodopa oral tablet	10-100 mg, 25-100 mg, 25-250 mg
RYTARY ORAL CAPSULE, EXTENDED RELEASE	23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG
selegiline hcl oral capsule	5 mg
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR	140 MG/ML, 70 MG/ML
ELIQUIS ORAL TABLET	2.5 MG; 5 MG
XARELTO ORAL TABLET	10 MG, 20 MG
warfarin oral tablet	1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg

Selected listed drugs (examples)mixed

ZEPOSIA ORAL CAPSULE 0.92 MG	Drug Tier = 6; Requirements / Limits = PA; S; QL (1 per 1 day)
ZUNVEYL ORAL TABLET, DELAYED RELEASE (DR/EC)	10 MG, 15 MG, 5 MG; Requirements / Limits = PA; QL (2 per 1 day)
AMRIX ORAL CAPSULE, EXTENDED RELEASE 24HR	15 MG, 30 MG; Requirements / Limits = PA
baclofen oral tablet	10 mg, 20 mg, 5 mg; Drug Tier = 3
XTAMPZA ER ORAL CAP, SPRINKL, ER12HR	9 MG, 13.5 MG, 18 MG, 27 MG, 36 MG; Requirements / Limits = PA; QL (2 per 1 day)

Additional listed drugsmixed

PERCOCET ORAL TABLET	5-325 MG; 7.5-325 MG; 10-325 MG; Requirements / Limits = OP; QL examples provided
PRIMLEV ORAL TABLET	5-300 MG; 7.5-300 MG; 10-300 MG; Requirements / Limits = OP; QL examples provided
PROLATE ORAL SOLUTION 10-300 MG/5 ML	Requirements / Limits = PA; OP; QL (20 per 1 day)

Drug listings (names and strengths as shown)mixed

ROXICODONE ORAL TABLET 15 MG; 30 MG	Drug Tier = NF; Requirements / Limits = OP; QL (3 per 1 day) for 15 mg; PA; OP; QL (2 per 1 day) for 30 mg
ROXYBOND ORAL TABLET (ORAL ONLY)	5 MG, 10 MG, 15 MG, 30 MG; Requirements / Limits = PA; OP; QL (varies)
TREZIX ORAL CAPSULE 320.5-30-16 MG	Requirements / Limits = OP; QL (8 per 1 day)
XTAMPZA ER ORAL CAP, SPRINKL, ER12HR	see above entries for strengths and QL
xyvona oral tablet	2 mg, 3 mg; Requirements / Limits = PA; OP; QL (4 per 1 day for 2 mg; 2 per 1 day for 3 mg)

Opioids and ER productsmixed

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR	50 MG; 100 MG; 150 MG; 200 MG; 250 MG; Requirements / Limits = PA; QL examples (2 per 1 day, 4 per 1 day depending on strength)
OPVEE NASAL SPRAY, NON-AEROSOL 2.7 MG/ACTUATION	Drug Tier = 3; Requirements / Limits = QL (example)
PERCOCET ORAL TABLET	see listings above for strengths and QL

Non-narcotic analgesics and NSAIDsmixed

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG	Drug Tier = NF; Requirements / Limits = PA
naproxen oral tablet 250 mg, 375 mg, 500 mg	Drug Tier = 3; Requirements / Limits = none listed
aspirin oral tablet, delayed release (dr/ec) 81 mg	Drug Tier = 3; Requirements / Limits = ACA

Extended release and specialty opioidsmixed

XTAMPZA ER ORAL CAP, SPRINKL, ER12HR	multiple strengths; Requirements / Limits = PA; QL (2 per 1 day)
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR	see opioid group; PA; QL thresholds

Formulary drug listing (products and strengths)mixed

ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS, DOSE PACK 5 MG (74 TABS)	Requirements / Limits = QL (74 per 30 days)
ELIQUIS ORAL TABLET 2.5 MG	Requirements / Limits = QL (2 per 1 day)
ELIQUIS ORAL TABLET 5 MG	Requirements / Limits = QL (74 per 30 days)
XARELTO DVT-PE TREAT 30D START ORAL TABLETS, DOSE PACK 15 MG (42)-20 MG (9)	Requirements / Limits = QL (51 per 30 days)

Prescriber and Pharmacy Obligations

Documentation Required

Follow Requirements / Limits listed

Many drugs listed in the formulary carry Quantity Limits (QL) and/or other Requirements / Limits (for example: PA, S, ST, ONC). Prescribers and pharmacies must follow the Requirements / Limits shown on each formulary row. When a product lists a QL, the plan limits the amount dispensed per fill or per day; requests above that limit require medical necessity review and supporting documentation.

Follow the Requirements / Limits column exactly (examples: PA = prior authorization required; QL = quantity limit; S = specialty; ST = step therapy; ONC = oncology benefit).
Quantity limits are explicitly specified in many entries (eg, QL (2 per 1 day), QL (21 per 28 days), QL (3.5 per 28 days), QL (1 per 28 days), QL (24 per 30 days)).
Requests exceeding a stated QL will be reviewed for medical necessity and may be denied if not supported.
Documentation for QL exceedance should include diagnosis, prior alternatives tried, prior use of the requested product within QL, and evidence of efficacy and safety at the requested quantity.

Denial Risk

Quantity limit enforcement

Quantity limits are enforced at claim adjudication. Claims that exceed the plan’s QL or that lack required prior authorization, step therapy fulfillment, or specialty handling may be rejected or returned for review.

Pharmacies should verify the per-fill or per-day QL before dispensing; common QL formats in the table include per day, per fill, per 28 days, or per 30 days.
If a prescription exceeds the QL, submit clinical justification and relevant supporting records to the prior authorization review showing medical necessity and prior therapy trials.
For specialty products marked S plus QL, both specialty channel requirements and quantity limits apply; coordinate with the specialty pharmacy as needed.

Step Therapy

Step therapy present / No step therapy specified

Some products are subject to Step Therapy (ST) while others have no step therapy requirement. Check the Requirements / Limits flag for ST when prescribing certain biologics and PCSK9 inhibitors — the formulary marks several PCSK9 inhibitors and other biologic products with ST and QL.

When ST is present (marked ST), the patient must have tried and failed the required agent(s) before coverage for the requested product will be approved.
When no ST is specified, step therapy is not required; however other flags (PA, QL, S) may still apply and must be followed.
Examples: REPATHA products are marked ST and have specific QL values per 28 days; other PCSK9/biologic entries in the formulary include ST or PA indicators — confirm the exact Requirements / Limits for each NDC/formulation.

Documentation Required

Quantity limits documentation; support for biologics and PCSK9 inhibitors

Provider action — supply documentation when requesting exceptions to quantity limits or when prior authorization/step requirements apply. For many biologics and PCSK9 inhibitors, the plan requires supporting clinical information to approve quantities or override ST/PA.

Include diagnosis, previous medications tried (with dates and outcomes), dosing plan, and evidence supporting the requested quantity or step override.
For products flagged PA; S; QL or ST; QL, submit specialty pharmacy documentation and dosing schedule to support the requested amount.
Failure to provide required documentation may result in denial or delay of coverage.

Summary	Supporting note
Try required first-line agents before coverage of step therapy drug
If alternatives have not been tried, provider/patient must obtain approval before the medicine will be covered at the lowest copay/coinsurance (Step Therapy definition).

Observation	Example / implication
Step therapy (S) applies to many oncology and specialty agents listed in the formulary.
Numerous oncology oral agents in the URINARY TRACT AGENTS section show PA; ONC; S flags indicating specialty/step handling (e.g., AFINITOR DISPERZ, GAVRETO, GLEEVEC).

Statement	Detail
No explicit step therapy sequences are provided in this excerpt.
The document shows S/ST flags but does not list ordered step sequences or required prior agents within these chunks.

Flag	Example
ST (step therapy) flag present on some products
Carbidopa-levodopa extended-release entries and REPATHA devices are annotated with ST in the formulary (e.g., RYTARY entries and REPATHA devices).

Note	Operational guidance
Some products are flagged with program indicators such as OP (opioid program), S (specialty) or other flags.
When OP or S flags appear alongside PA/QL, follow the plan's opioid/specialty program and step requirements as indicated on the formulary rows.

Relationship between ST and PA	Example
Some extended‑release and specialty opioids that are flagged (e.g., NUCYNTA ER) require prior authorization in addition to any program flags.
NUCYNTA ER is listed with Requirements / Limits = PA; QL (2 per 1 day) indicating PA is required before coverage; OP flag is used for opioid program monitoring.

Presence	Examples
Step therapy is present for some agents in the formulary.
Examples include TRINTELLIX listed with ST; zolpidem extended‑release entries listed with ST and associated QL values.

Observation	Detail
For some oral anticoagulants and specialty biologics, QL and PA are provided but explicit step sequences are not listed in these chunks.
Examples: ARIXTRA entries show PA; QL (24 per 30 days) and PCSK9/biologic products (REPATHA, PRALUENT) show QL and PA/ST flags without detailed step sequences.

Product	Formulary flag
REPATHA pushtRONEX wearable injector; REPATHA SureClick; REPATHA syringe
Requirements / Limits = ST; QL (3.5 per 28 days for PushtRONEX; 2 per 28 days for SureClick/Syringe) indicating step therapy applies to REPATHA devices.

Quantity Limits (QL) by Product

inv-124: nystatin oral suspension 100,000 unit/ml — 480

Productnystatin oral suspension 100,000 unit/ml

Quantity limit480 per fill

Table locationListed under antifungal entries with Requirements / Limits = QL (480 Per fill)

inv-125: VIVJOA ORAL CAPSULE 150 MG — 18

ProductVIVJOA ORAL CAPSULE 150 MG

Quantity limitQL (18 per 84 days)

RequirementsRequirements / Limits = PA; QL (18 per 84 days)

inv-126: LAGEVRIO (molnupiravir) — 8

ProductLAGEVRIO (molnupiravir) ORAL CAPSULE 200 MG

Quantity limitQL (8 per 1 day)

NotesListed as EUA product with QL (8 per 1 day)

inv-127: oseltamivir (various strengths) — 10-180

Productoseltamivir (various strengths)

Quantity limitsRanges shown: QL (10 Per fill), QL (20 Per fill), QL (180 Per fill) depending on formulation/strength

Table examples30 mg listed QL (20 Per fill); 45/75 mg listed QL (10 Per fill); suspension listed QL (180 Per fill)

inv-128: PAXLOVID — 4-6

ProductPAXLOVID oral tablets, dose pack

Quantity limitsQL (4 per 1 day) and QL (6 per 1 day) depending on pack formulation

NotesDifferent dose‑pack configurations have QL (4 per 1 day) or QL (6 per 1 day)

inv-129: ARIKAYCE / inhaled tobramycin products / TOBI — 4-5; 252 per 30 days for ARIKAYCE

ProductsARIKAYCE and inhaled tobramycin/TOBI products

Typical quantity limitsQL (4-5 per 1 day) for inhalation formulations; ARIKAYCE also listed as 252 per 30 days

RequirementsMany inhaled formulations flagged PA; S and have per‑day QL (4 or 5) depending on formulation

inv-130: TEMBEXA — 65

ProductTEMBEXA ORAL TABLET

Quantity limitQL (65 per 8 days)

ContextListed with QL value as shown in antiviral section

inv-131: TOBI INHALATION SOLUTION for nebulization 300 mg/5 ml — QL (5 per 1 day) or QL (4 per 1 day) depending on formulation

ProductTOBI inhalation solution for nebulization 300 mg/5 ml

Quantity limitsQL (5 per 1 day) or QL (4 per 1 day) depending on specific formulation

RequirementsEntries show Requirements / Limits = PA; S and per‑day QL tied to formulation

inv-132: BLUJEPA ORAL TABLET 750 MG — QL (20 Per fill)

ProductBLUJEPA ORAL TABLET 750 MG

Quantity limitQL (20 Per fill)

RequirementsRequirements / Limits = PA; QL (20 Per fill)

inv-133: fosfomycin tromethamine oral packet 3 gram — QL (3 Per fill)

Productfosfomycin tromethamine oral packet 3 gram

Quantity limitQL (3 Per fill)

Table noteListed under urinary tract agents with QL (3 Per fill)

inv-134: IBRANCE — 21

ProductIBRANCE (palbociclib)

Quantity limitQL (21 per 28 days)

RequirementsRequirements / Limits = PA; ONC; S; QL (21 per 28 days)

inv-135: KISQALI 200 mg/day — 21

ProductKISQALI (ribociclib) 200 mg/day

Quantity limitQL (21 per 28 days)

NotesHigher daily doses have proportional QL values (e.g., 42 per 28 days for 400 mg/day)

inv-136: LENVIMA (selected strengths) — 1-3

ProductLENVIMA (selected strengths)

Quantity limitsQL (1-3 per 1 day) depending on strength

RequirementsListed with PA; ONC; TD; S and strength‑dependent QL

inv-137: ROZLYTREK (various strengths) — 1 or 3

ProductROZLYTREK (entrectinib) various strengths

Quantity limitsQL (1 per 1 day) or QL (3 per 1 day) depending on strength

RequirementsRequirements / Limits = PA; ONC; TD; S; QL (1 per 1 day) for some formulations

inv-138: NILOTINIB — 4

ProductNILOTINIB (nilotinib) oral capsule

Quantity limitQL (4 per 1 day)

RequirementsRequirements / Limits = PA; ONC; TD; S; QL (4 per 1 day)

inv-139: REVLIMID 20/25 mg — 21

ProductREVLIMID (lenalidomide) 20/25 mg

Quantity limitQL (21 per 28 days)

RequirementsRequirements / Limits = PA; ONC; S; QL (21 per 28 days)

inv-140: ROZLYTREK 200 mg capsule — 3

ProductROZLYTREK 200 mg capsule

Quantity limitQL (3 per 1 day)

RequirementsListed with PA; ONC; TD; S and QL (3 per 1 day) for 200 mg capsule

inv-141: VENCLEXTA 100 mg — 6

ProductVENCLEXTA 100 mg

Quantity limitQL (6 per 1 day)

RequirementsRequirements / Limits = PA; ONC; S; QL (6 per 1 day)

inv-142: VOYXACT subcutaneous syringe 400 mg/2 mL — 1

ProductVOYXACT subcutaneous syringe 400 mg/2 mL

Quantity limitQL (1 per 28 days)

RequirementsListed with PA; S and QL (1 per 28 days)

inv-143: gabapentin oral solution 250 mg/5 ml — 72

Productgabapentin oral solution 250 mg/5 ml

Quantity limitQL (72 per 1 day)

RequirementsListed with QL (72 per 1 day) for solution formulations

inv-144: gabapentin oral capsule 100 mg, 300 mg — 12

Productgabapentin oral capsule 100 mg, 300 mg

Quantity limitQL (12 per 1 day)

NotesCapsule strengths listed with QL (12 per 1 day)

inv-145: gabapentin oral tablet 600 mg — 6

Productgabapentin oral tablet 600 mg

Quantity limitQL (6 per 1 day)

Notes600 mg tablet listed with QL (6 per 1 day)

inv-146: VALTOCO nasal spray — 5

ProductVALTOCO nasal spray

Quantity limitQL (5 Per fill)

RequirementsRequirements / Limits = PA; QL (5 Per fill)

inv-147: LIBERVANT buccal film — 2

ProductLIBERVANT buccal film

Quantity limitQL (2 Per fill)

RequirementsRequirements / Limits = PA; QL (2 Per fill)

inv-148: Aimovig autoinjector — 1

ProductAimovig autoinjector

Quantity limitQL (1 per 28 days)

RequirementsRequirements / Limits = PA; QL (1 per 28 days)

inv-149: Ajovy autoinjector — 1.5

ProductAjovy autoinjector

Quantity limitQL (1.5 per 28 days)

NotesAjovy autoinjector entry shows QL (1.5 per 28 days)

inv-150: Ajovy syringe — 4.5

ProductAjovy syringe (225 mg/1.5 mL)

Quantity limitQL (4.5 per 84 days)

RequirementsRequirements / Limits = PA; QL (4.5 per 84 days)

inv-151: Elyxyb oral solution — 144

ProductElyxyb oral solution

Quantity limitQL (144 per 30 days)

RequirementsRequirements / Limits = PA; QL (144 per 30 days)

inv-152: Qulipta — 1

ProductQulipta

Quantity limitQL (1 per 1 day)

RequirementsListed with QL (1 per 1 day)

inv-153: meprobamate oral tablet — QL (6 per 1 day)

Productmeprobamate oral tablet

Quantity limitQL (6 per 1 day)

RequirementsRequirements / Limits = PA; QL (6 per 1 day)

inv-154: PYRIDOSTIGMINE BROMIDE oral tablet 30 mg — QL (1 per 1 day)

ProductPYRIDOSTIGMINE BROMIDE oral tablet 30 mg

Quantity limitQL (1 per 1 day)

NotesListed with QL (1 per 1 day)

inv-155: buprenorphine hcl sublingual tablet 2 mg — QL (12 per 1 day)

Productbuprenorphine hcl sublingual tablet 2 mg

Quantity limitQL (12 per 1 day)

NotesPer‑day QL listed for sublingual buprenorphine 2 mg

inv-156: SOMA oral tablet — QL (4 per 1 day)

ProductSOMA oral tablet

Quantity limitQL (4 per 1 day)

RequirementsRequirements / Limits = QL (4 per 1 day)

inv-157: fentanyl transdermal patch 72 hour (certain strengths) — QL (10 per 30 days)

Productfentanyl transdermal patch 72 hour (certain strengths)

Quantity limitQL (10 per 30 days)

NotesSpecified strengths listed with QL (10 per 30 days)

inv-158: HYSINGLA ER oral tablet (various strengths) — QL (1-4 per 1 day depending on strength)

ProductHYSINGLA ER oral tablet (various strengths)

Quantity limitQL (1-4 per 1 day) depending on strength

RequirementsDifferent strengths carry strength‑dependent per‑day QL (1–4 per day)

inv-159: morphine oral solution 10 mg/5 mL — QL (30 per 1 day)

Productmorphine oral solution 10 mg/5 mL

Quantity limitQL (30 per 1 day)

NotesMorphine solution listed with per‑day QL (30 per 1 day)

inv-160: XTAMPZA ER oral capsule — QL (2 per 1 day)

ProductXTAMPZA ER oral capsule

Quantity limitQL (2 per 1 day)

RequirementsListed with PA; QL (2 per 1 day)

inv-161: PERCOCET 5-325 MG — 8

ProductPERCOCET 5-325 MG

Quantity limit8 per 1 day

RequirementsRequirements / Limits = OP; QL (8 per 1 day)

inv-162: ROXICODONE 15 MG — 3

ProductROXICODONE 15 MG

Quantity limit3 per 1 day

RequirementsRequirements / Limits = OP; QL (3 per 1 day)

inv-163: ketorolac injection (various) — 20

Productketorolac injection (various)

Quantity limitQL (20 per 30 days)

NotesApplies to injection/syringe/formulations listed with QL (20 per 30 days)

inv-164: tramadol oral tablet 25 MG — 16

Producttramadol oral tablet 25 MG

Quantity limitQL (16 per 1 day)

RequirementsListed with OP/PA flags and QL values depending on formulation

inv-165: ADZENYS XR-ODT ORAL TABLET (various strengths) — 1 per 1 day for 12.5/15.7/18.8 mg strengths; 2 per 1 day for 3.1/6.3/9.4 mg strengths

ProductADZENYS XR-ODT ORAL TABLET (various strengths)

Quantity limitsQL (1 per 1 day) for 12.5/15.7/18.8 mg strengths; QL (2 per 1 day) for 3.1/6.3/9.4 mg strengths

RequirementsRequirements / Limits = PA; QL per strength

inv-166: alprazolam intensol oral concentrate 1 mg/ml — QL (6 per 1 day); inv-167: alprazolam oral tablet 2 mg — QL (3 per 1 day)

Productalprazolam intensol oral concentrate 1 mg/ml and alprazolam oral tablet 2 mg

Quantity limitsIntensol concentrate: QL (6 per 1 day); tablet 2 mg: QL (3 per 1 day)

RequirementsEntries show QL per day limits for various alprazolam formulations

inv-168: armodafinil oral tablet 150/200/250 mg — QL (1 per 1 day) ; 50 mg listed as QL (2 per 1 day)

Productarmodafinil oral tablet 150/200/250 mg (and 50 mg)

Quantity limitsQL (1 per 1 day) for 150/200/250 mg; QL (2 per 1 day) for 50 mg

RequirementsListed with QL values by strength

inv-169: DAYTRANA TRANSDERMAL PATCH — QL (1 per 1 day)

ProductDAYTRANA TRANSDERMAL PATCH

Quantity limitQL (1 per 1 day)

RequirementsListed with QL (1 per 1 day)

inv-170: TRINTELLIX oral tablet — QL (1 per 1 day)

ProductTRINTELLIX oral tablet

Quantity limitQL (1 per 1 day)

RequirementsRequirements / Limits = ST; QL (1 per 1 day)

inv-171: XYREM oral solution 500 mg/mL — QL (18 per 1 day)

ProductXYREM oral solution 500 mg/mL

Quantity limitQL (18 per 1 day)

RequirementsRequirements / Limits = PA; S; QL (18 per 1 day)

inv-172: ZURZUVAE oral capsule 20 mg, 25 mg — QL (28 per 273 days)

ProductZURZUVAE oral capsule 20 mg, 25 mg

Quantity limitQL (28 per 273 days)

RequirementsRequirements / Limits = PA; S; QL (28 per 273 days)

inv-173: AVONEX intramuscular pen/syringe — QL (1 per 28 days)

ProductAVONEX intramuscular pen/syringe

Quantity limitQL (1 per 28 days)

RequirementsRequirements / Limits = PA; S; QL (1 per 28 days)

inv-174: CARDAMYST nasal spray; KERENDIA; QBRELIS; UPTRAVI and others as annotated — examples shown (e.g., QL 2 per 22 days for CARDAMYST; KERENDIA QL 1 per 1 day)

ExamplesCARDAMYST nasal spray QL (2 per 22 days); KERENDIA QL (1 per 1 day); QBRELIS examples shown

ContextVarious cardiovascular and nasal products show specific per‑period QL values in the table

ActionFollow per‑product QL as listed to avoid claim denials

inv-175: ARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML — QL (24 per 30 days)

ProductARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML

Quantity limitQL (24 per 30 days)

RequirementsRequirements / Limits = PA; QL (24 per 30 days)

inv-176: ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS (5 MG, 74 TABS) — QL (74 per 30 days)

ProductELIQUIS DVT-PE TREAT 30D START ORAL TABLETS (5 MG, 74 TABS)

Quantity limitQL (74 per 30 days)

NotesPack-specific QL listed for DVT-PE start dose pack

inv-177: enoxaparin subcutaneous solution 300 mg/3 ml — QL (6 per 1 day)

Productenoxaparin subcutaneous solution 300 mg/3 ml

Quantity limitQL (6 per 1 day)

Table noteEnoxaparin 300 mg/3 ml listed with QL (6 per 1 day)

inv-178: XARELTO DVT-PE TREAT 30D START dose pack — 51

ProductXARELTO DVT-PE TREAT 30D START dose pack

Quantity limit51 per 30 days

NotesDose pack QL (51 per 30 days) shown in table

inv-179: XARELTO oral tablet 10/20 mg — 1

ProductXARELTO oral tablet 10/20 mg

Quantity limitQL (1 per 1 day)

NotesPer‑day QL shown for 10/20 mg tablets

inv-180: PRALUENT PEN — 2

ProductPRALUENT PEN

Quantity limitQL (2 per 28 days)

RequirementsListed with QL (2 per 28 days)

inv-181: REDEMPLO — 1

ProductREDEMPLO subcutaneous syringe

Quantity limitQL (1 per 90 days)

RequirementsRequirements / Limits = PA; S; QL (1 per 90 days)

inv-182: REPATHA PUSHTRONEX wearable injector — 3.5

ProductREPATHA PUSHTRONEX wearable injector

Quantity limitQL (3.5 per 28 days)

RequirementsRequirements / Limits = ST; QL (3.5 per 28 days)

inv-183: REPATHA SURECLICK / SYRINGE — 2

ProductREPATHA SURECLICK / SYRINGE

Quantity limitQL (2 per 28 days)

RequirementsRequirements / Limits = ST; QL (2 per 28 days)

inv-184: BIMZELX auto-injector / syringe — 2

ProductBIMZELX auto-injector / syringe

Quantity limitQL (2 per 56 days)

RequirementsRequirements / Limits = PA; S; QL (2 per 56 days)

inv-185: IMULDOSA / OTULFI / PYZCHIVA / SELARSDI / other 45 mg products — 0.5 or 1

ProductsIMULDOSA / OTULFI / PYZCHIVA / SELARSDI and other 45 mg presentations

Quantity limitsQL (0.5 or 1 per 84 days) depending on presentation

RequirementsEntries show PA; S and QL (0.5 or 1 per 84 days) by presentation

inv-186: COSENTYX presentations — 0.5, 1 or 2

ProductCOSENTYX presentations

Quantity limitsQL (0.5, 1 or 2 per 28 days) depending on presentation

RequirementsListed with PA; S and presentation‑dependent QL

OpenPayer

HealthPartners HSA Plus 2026 Formulary (drug list) — Coverage & Utilization Rules

Coverage and Utilization Criteria

Drug Listings and Code Tables

Prescriber and Pharmacy Obligations

Step Therapy Requirements

Quantity Limits (QL) by Product

Specialty Pharmacy and Site Requirements

Abbreviations and Terms

Background and Context