Q1 drug formulary change notification

  • 03/15/2024

Key points

  • Hennepin Health is making several changes to its drug formulary for Q1 2024.
  • The changes apply to all Hennepin Health members.
  • Medicaid list of covered drugs (formulary) (PDF). A printed copy can be obtained by calling Provider Services at 612-596-1036 (select option 2).

Background

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 website. A printed copy can be obtained by calling Provider Services at 612-596-1036 (select option 2). 

Effective March 15, 2024, these medications were added:

  • Roflumilast tab, PDL
  • Amlodipine/valsartan/hydrochlorothiazide, PDL
  • Olmesartan tab, PDL
  • Olmesartan HCTZ, PDL

Effective March 15, 2024, these medications and Utilization Management (UM) requirements of prior authorization (PA) and/or quantity limits (QL) were added: 

  • XARELTO TAB 2.5 MG, PDL (QL = 2 tabs/day)
  • XARELTO STARTER PACK, PDL (QL = 1 pack/fill per calendar year)
  • VIIBRYD TAB 10 MG, PDL (QL = 0.5 tab/day; only one strength allowed per month)
  • VIIBRYD TAB 20 MG, PDL (QL = 0.5 tab/day; only one strength allowed per month)
  • VIIBRYD TAB 40 MG, PDL (QL = 1 tab/day; only one strength allowed per month)
  • Zolmitriptan Tablet, PDL (QL = 18 tabs/30 days)
  • ZOMIG SPRAY, PDL (QL = 1 box/fill; 3 fills/30 days)
  • ABILIFY ASIMTUFIL INJ, PDL (PA)
  • PERSERIS INJ, PDL (PA)
  • Lurasidone HCL tab 20mg, 40mg, 60mg, PDL (QL = 0.5 tab/day
  • Lurasidone HCL tab 80 mg, PDL (QL = 1 tab/day
  • Lurasidone HCL tab 120 mg, PDL (QL = 1 tab/day
  • INFLIXIMAB INJ, PDL (PA) (MB)
  • OTEZLA TAB, PDL (PA, QL = 2 tabs/day)
  • OTEZLA STARTER PACK, PDL (PA, QL = 1 pack/year)
  • ARNUITY ELLIPTA INHALER, PDL (QL = 1 inhaler/30 days)
  • JANUMET XR TAB, PDL (PA)
  • JENTADUETO XR TAB, PDL (PA)
  • NESINA TAB, PDL (PA)
  • OZEMPIC INJ, PDL (PA, QL = 1 pack/28 days)
  • Fingolimod Cap (GILENYA equiv), PDL (PA) 
  • Teriflunomide tab, PDL (PA)
  • Ciprofloxacin/dexamethasone otic susp, PDL (QL = 1 bottle/30 days)
  • Tobramycin neb soln (TOBI equiv) , PDL (PA)
  • Icatibant Inj, PDL (PA)
  • SEVENFACT INJ, PDL (PA) 
  • Sirolimus tab 0.5 mg, PDL (QL = 1 tab/day)
  • Sirolimus tab 1 mg, PDL (QL = 6 tabs/day)
  • Sirolimus tab 2 mg, PDL (QL = 1 tab/day)
  • Sirolimus soln, PDL (QL = 2 ml/day)
  • RENVELA PACKET 0.8 GM, PDL (QL = 6 packets/day)
  • RENVELA PACKET 2.4 GM, PDL, (QL = 3 packets/day)
  • Lisdexamfetamine dimesylate cap, PDL (QL = 1 cap/day; only one strength allowed per month
  • Mifepristone tab (MIFEPREX equiv), (QL = 1 tab/dispense)
  • MIFEPREX TAB (QL = 1 tab/dispense)

Effective March 15, 2024, these medications were removed: 

  • PEGANONE
  • IMITREX NASAL SPRAY
  • LATUDA TAB 20 MG, 40 MG, 60 MG
  • LATUDA TAB 80 MG
  • LATUDA TAB 120 MG
  • PROAIR HFA INHALER
  • Tiotropium (Spiriva Handlihaler) bromide cap inhaler 
  • Flovent Diskus Inhaler 
  • FLUTICASONE POWDER INH
  • FLOVENT HFA INHALER
  • INSULIN LISPRO PROTAMINE MIX KWIKPEN (AG)
  • AUBAGIO TAB
  • GILENYA CAP
  • CIPROCEX OTIC SUSP
  • RAPAMUNE TAB
  • RAPAMUNE SOLN
  • PHOSLYRA SOLN

Resources

 
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