2025 Q1 Drug Formulary Change Notification

• 02/28/2025

Hennepin Health has made several changes to the drug formulary. These changes apply to Hennepin Health-PMAP, Hennepin Health-MNCare and Hennepin Health-SNBC members. Members who are directly impacted will receive notification of the changes. The updated full drug formulary is available on the Hennepin Health website. A printed copy can be obtained by calling Provider Services at 612-596-1036 (select option 2).

Effective March 1, 2025, these medications have utilization management (UM) requirements:

• tranexamic acid tab: removed prior authorization, added quantity limit = 30 tabs/30 days
• estradiol valerate 10 mg/ml inj: added quantity limit = 5 ml/30 days
• estradiol valerate 20 mg/ml inj: added quantity limit = 5 ml/30 days
• fluocinolone otic oil (DERMOTIC equiv): removed prior authorization; added quantity limit = 1 bottle/30 days
• tramadol tab 100 mg (ULTRAM equiv): added prior authorization and quantity limit = 4 tabs/day
• lamotrigine ER tab; added quantity limit = 2 tabs/day

Resources:

• Hennepin Health Customer Services: 612-596-1036 (select the provider services option)
• List of covered drugs (Formulary)
• Hennepin Health website: hennepinhealth.org