Frequently asked questions for Hennepin Health SNBC plan members who joined April 1, 2025.
Hennepin Health is making several changes to its drug formulary for Q1 2025. 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 website. A printed copy can be obtained by calling Provider Services at 612-596-1036 (select option #2). Effective 01/01/2025, these medications were added and with a quantity limit if indicated: Qudexy XR; QL = 1 cap/day, only one strength allowed per month (for 25 mg, 50 mg, 100 mg, 150 mg); QL = 2 caps/day, only one strength allowed per month (for 200 mg cap) Dexcom G7 CGM; QL = 1 receiver/year Freestyle Libre 3 Reader CGM; QL = 1 receiver/hear Linzess Lubiprostone Asmanex HFA; QL= 1 inhaler/30 days Qvar Redihaler; QL= 1 inhaler/30 days Mavyret pellet pack Xolair syringe/autoinj Xolair vial Kloxxado; QL = 2 sprays/fill Rextovy; QL = 2 sprays/fill Clobazam susp; QL = 240ml/30 days Effective 01/01/2025, these medications were removed from the preferred drug list (PDL) and require a prior authorization: Felbatol Gabitril Carbatrol Zonegran Aerospan Airduo Digihaler Armonair Digihaler Peg Intron Peg Intron Redipen Rebetol Solution RibaPak Ribasphere Viekira Pak Kombiglyze Nesina Onglyza Adlyxin Kazano Oseni Levemir pens and vials Insulin glargine vial Insulin glargine Solostar pen Semglee pen Ventavis Avelox Cipro XR Effective 01/01/2025, these medications are now nonpreferred on the PDL drug list and require a prior authorization and a quantity limit if indicated: Methsuximide Adalimumab-ryvk inj Cosentyx vial Omvoh pen Omvoh syringe Omvoh vial Rinvoq LQ Simlandi Autoinjector Spevigo syringe Tyenne vial Tyenne pen Tyenne syringe Tofidence Velsipity Zymfentra pen Zymfentra syringe Alosetron Ibsrela Lotronex Motegrity Movantik Relistor oral Relistor syringe Relistor vial Symproic Trulance Vibrezi Fluticasone (inhalation); QL = 1 inhaler/30 days Vosevi Epclusa pellet pack Liraglutide; QL = 9 ml/30 days Sitagliptin Sitagliptin/Metformin Zituvio Insulin glargine Max Solostar pen Cinqair Fasenra pen Fasenra syringe Nucala autoinjector Nucala syringe Nucala vial Tezspire pen Texspire syringe Zoryve cream Opsynvi tablet Tadliq L-glutamine powder pack Adderall XR; QL=1 cap/day, only one strength allowed per month Concerta; QL = 1 cap/day, only one strength allowed per month Amphetamine salt combo ER Methylphenidate ER; QL = 1 cap/day, only one strength allowed per month Relexxii Effective 01/01/2025, these medications have inactive GPIs: COVID-19 Vaccine Inj (Janssen, NDC 59676058005) COVID-19 Vaccine Inj (Janssen, NDC 59676058015) COVID-19 Vaccine Inj 6M-11Y (Moderna, 25MCG/0.25ML, NDC 17100002401830) COVID-19 Vaccine Bivalent Boost Inj 6MO-5YR (Moderna, NDC 17100002421825) COVID-19 Vaccine Bivalent Booster Inj (Moderna, NDC 17100002421835) COVID-19 Vaccine Bivalent Booster Inj (Pfizer, NDC 17100002441820) COVID-19 Vaccine Bivalent Booster Inj 5-11Y (Pfizer, NDC 17100002441830) COVID-19 Vaccine Bivalent Booster Inj 6MO-4Y (Pfizer, NDC 17100002441840) COVID-19 Vaccine Inj (Novavax, NDC 17100002601820) Fluzone HD PF Inj (NDC 17100002024E6) Flulaval Quadrivalent Inj (NDC 1710000202518) Fluarix Quad Inj; Fluzone Quad Inj (NDC1710002025E6) Fluad Quad Inj (NDC 1710002047E4) Flumist Quadrivalent Nasal Susp (NDC 171000205418) Flucelvax Quad Inj (NDC 171000208218) Flucelvax Quad Inj (NDC 1710002082E6) Flublok Quad Inj (NDC 1710002086E5) Effective 01/01/2025, these medications and UM requirements of Prior Authorizations and/or Quantity Limits (QL) were added: Cue Health Monitor, PA, QL = 1 kit/year Cue COVID-19 Inj Test Cartridge, PA, QL = 8 cartridges/30 days COVID-19 Test, QL = 8 tests/30 days Lagevrio Cap, 200 mg, QL = 40 caps/fill Lagevrio Cap (EUA), QL = 40 caps/fill Paxlovid Tab 150-100 mg; QL = 20 tabs/fill Paxlovid Tab 300-100 mg; QL = 30 tabs/fill Paxlovid Tab (EUA); PA, QL = 30 tabs/fill Paxlovid Pack (EUA);PA, QL = 20 tabs/fill Freestyle Libre 2 Receiver; QL = 1 receiver/year Freestyle Libre 2-Plus Sensor; PA, QL = 2 sensors/30 days Mavyret tab, PA Effective 01/01/2025, these UM requirements of Prior Authorizations (PA) or Quantity Limits (QL) were removed: Lamotrigine ER tab, remove PA Mavyret tab, remove QL
Effective 01/01/2025, the 90DS indicator was added to these medications: dextromethorphan ER liquid 30mg/5ml mycophenolate mofetil cap cyclosporine modified cap, gengraf cap pilocarpine tab atropine ophth soln pentoxifylline ER tab prasugrel tab potassium chloride micro tab potassium chloride ER tab 10meq potassium chloride ER cap bromocriptine tab amantadine syrup primidone tab levetiracetam soln levetiracetam tab, roweepra tab carbamazepine ER tab carbamazepine tab diclofenac sodium SR tab donepezil tab chlorpromazine tab risperidone soln doxepin cap desipramine tab amitriptyline tab 150mg mirtazapine ODT tolterodine ER cap sulfasalazine DR tab sulfasalazine tab ursodiol tab ursodiol cap roflumilast tab albuterol neb soln 1.25mg ipratropium nasal spray pravastatin tab cholestyramine powder pack spironolactone/hydrochlorothiazide tab metolazone tab bumetanide tab amlodipine/valsartan tab prazosin cap guanfacine IR tab enalapril tab verapamil ER cap verapamil ER tab nifedipine ER tab felodipine ER tab propranolol oral soln 20mg/5ml propranolol tab nitroglycerin SL tab isosorbide mononitrate tab digoxin soln raloxifene tab jinteli tab estradiol/norethindrone tab fludrocortisone tab tamoxifen tab entecavir tab emtricitabine/tenofovir disoproxil fumarate tab tenofovir disoproxil fumarate tab dextromethorphan ER liquid Effective 01/01/2025, the 90DS indicator was removed from these medications: azathioprine tab dorzolamide/timolol ophth soln fluphenazine tab