2025 Q2 Drug Formulary Change Notification

06/17/2025

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 June 17, 2025, these medications were removed from the Preferred Drug List and require prior authorizations:

Arymo ER
Duragesic Matrix
Embeda
Exalgo
Nucynta ER
Xtampza ER
Brisdelle
Pexeva
Cesamet
Zofran ODT
Zofran solution
Zofran tablets
Clarinex
Trudhesa
Amerge
Niaspan
Niacor
Triglide
Vascepa
Fazaclo
Risperdal ODT
Symbyax
Extavia Kit and vial

Effective June 17, 2025, these medications have utilization management requirements:

Lacosamide suspension: added to the preferred drug list, removed prior authorization, added quantity limit = 1200 ml/30 days
Levetiracetam tablets (AG): requires prior authorization
Fexofenadine OTC: added to the preferred drug list; removed prior authorization; added quantity limits of QL = 2 tabs/day for 60 mg tab; QL = 1 tab/day for 180 mg tab
Fexofenadine suspension: added to the preferred drug list; removed prior authorization; added quantity limit QL = 10 ml/day
Vyalev: requires prior authorization
Erzofri; requires prior authorization
Opipza; requires prior authorization
Risperidone (Intramuscular); requires prior authorization
Adalimumab-AACF syringe and pen; requires prior authorization
Adalimumab-AATY syringe and pen: requires prior authorization
Simlandi syringe; requires prior authorization
Steqeyma syringe; requires prior authorization
Wezlana vial (subcutaneous & intravenous); requires prior authorization
Wezlana syringe (subcutaneous); requires prior authorization
Yesintek syringe and vial; requires prior authorization
Extavia kit and vial; requires prior authorization
Ocrevus Zunovo; requires prior authorization
Oxycodone tab (Roxybond equiv); requires prior authorization; quantity limit QL = 4 tabs/day
Ocrevus; requires prior authorization

RESOURCES

Hennepin Health Customer Services: 612-596-1036 (press 2)
Hennepin Health website: www.hennepinhealth.org