2025 Q2 Drug Formulary Change Notification

• 04/01/2025

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

• Tekturna HCT, removed from Preferred Drug List, prior authorization (PA) added 
• Accupril, removed from Preferred Drug List, covered with PA 
• Entresto sprinkle cap, covered with PA 
• Desvenlafaxine ER (Sun labeler), added Preferred Drug List (PDL) indicator, removed PA, added quantity limit (QL) = 1 tab/day; only one strength allowed per month 
• Desvenlafaxine ER (generic of Pristiq), added PDL indicator, removed PA, added QL = 1 tab/day; only one strength allowed per month 
• Zurzuvae, covered with PA 
• Perseris, removed from PDL, covered with PA 
• Paliperidone (oral), 1.5 mg, 3 mg and 9 mg (INVEGA equiv) added PDL indicator, removed PA, added QL = 1 tab/day; only one strength allowed per month  
• Paliperidone (oral) (INVEGA equiv) 6mg; added PDL indicator, removed PA, added QL = 2 tabs/day; only one strength allowed per month 
• Cobenfy, covered with PA 
• Ohtuvayre, covered with PA 
• Accu-Chek Nano Smartview, removed from PDL, covered with PA and QL = 1 meter/365 days 
• Accu-Chek Aviva Plus, covered with PA and QL = 1 meter/365 days 
• Contour Next, remove PDL indicator, covered with PA and QL = 1 meter/365 days 
• Contour Next Gen, covered with PA 
• Accu-Chek Compact Plus, removed from PDL; covered with PA 
• Crestor, removed from PDL, covered with PA 
• Flolipid suspension, covered with PA 
• Pitavastatin calcium, covered with PA 
• Renvela Powder Pack, remove PDL indicator, covered with PA and QL = 6 packets/day for 0.8 GM strength; and 3 packets/day for 2.4 GM strength 
• Sevelamer carbonate powder pack, remove PA, added PDL indicator, added QL = 6 packets/day for 0.8 GM strength and 3 packets/day for 2.4 GM strength 
• Xphozah tablet, covered with PA 
• Buprenorphine (Transderm), removed PA, add PDL indicator, and QL = 4 patches/28 days; only one strength allowed per month 
• Synjardy, added PDL indicator and PA 
• Synjardy XR, added PDL indicator and PA 
• Xigduo XR, added PDL indicator and PA 
• Lialda, removed PDL indicator, covered with PA 
• Mesalamine (oral) (generic of Lialda), added PDL indicator, and QL = 4 tabs/day 

Resources

• Hennepin Health Customer Services: 612-596-1036 (press 2)  
• Hennepin Health website  
• List of covered drugs | Hennepin Health