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Frequently asked questions for Hennepin Health SNBC plan members who joined April 1, 2025.

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2025 Q1 Drug Formulary Change Notification

  • 12/01/2024

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

Resources

  • Hennepin Health Customer Services: 612-596-1036 (select option 2) 
  • Forms/documents | Hennepin Health
  • Hennepin Health website: hennepinhealth.org
 
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