What is the HealthPartners Formulary?
A formulary is a list of drugs selected by HealthPartners, in consultation with a team of healthcare providers, representing the prescription therapies believed to be a necessary part of a quality treatment program. HealthPartners will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a HealthPartners network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Yes, HealthPartners may add or remove drugs from our formulary during the year. The formulary on this website may be updated monthly.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify members who take the drug of the change at least 60 days before the date that the change becomes effective. If a member requests a refill of a discontinued drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we'll immediately remove the drug from our formulary and provide notice to members who take that drug.
If we no longer cover your drugs, please talk with your doctor about appropriate alternative therapies available on our new formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary or tiering exception. If approved, we will start covering your drug starting on January 1st. After January 1, you will get a temporary supply of the drug while you talk to your doctor about switching to a covered drug, or request a formulary or tiering exception.
How do I use the formulary?
The first column of the chart lists the drug name. Brand-name drugs are capitalized and generic drugs are listed in lower-case italics.
The information in the Requirements/Limits column tells you if your HealthPartners plan has any special requirements for coverage of your drug.
How much will I pay for HealthPartners covered drugs?
If you qualified for extra help with your drug costs, your costs for your drugs may be different than those described in your Evidence of Coverage. The amount you pay depends on whether you fill prescription(s) at a network pharmacy, out-of-network pharmacy, or a mail-order pharmacy.
For those who have a yearly deductible, after you meet your yearly deductible, HealthPartners will pay part of the costs for your covered drugs and you'll pay part.
Are there any restrictions on coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: HealthPartners requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that aren't on the formulary and were approved for coverage through our exceptions process.) This means you'll need to get approval from HealthPartners before you fill your prescription. If you don't get approval, HealthPartners may not cover the drug.
- Quantity Limits: HealthPartners limits the amount of certain drugs that we'll cover. For example, we provide 20 units per prescription of Ergomar. This may be in addition to a standard 30- or 90-day supply.
- Step Therapy: In some cases, HealthPartners requires you to first try certain drugs to treat your medical condition before we'll cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, HealthPartners may not cover Drug B unless you try Drug A first. If Drug A doesn't work for you, HealthPartners will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking at the formulary. Step Therapy can also mean the drug is reserved for certain physician specialists. For example, Drug A may process automatically for a gastroenterologist, but will require prior authorization for other physicians.
What if my drug isn't on the Formulary?
If your drug isn't included in this formulary, you should first contact Member Services and ask if your drug is covered. If you learn that HealthPartners doesn't cover your drug, you have two options:
- You can call Member Services to order a printed formulary. When you receive the formulary, show it to your doctor and ask him or her to prescribe a similar drug that HealthPartners covers.
- You can ask HealthPartners to make an exception to cover your drug. See next question and answer.
You can ask HealthPartners to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:
- You can ask us to cover your drug even if it's not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, HealthPartners limits the amount of certain drugs we'll cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
What are generic drugs?
A generic drug has the same active-ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are approved by the FDA.
Where can I get more information?
For detailed information about your HealthPartners prescription coverage, please review your Evidence of Coverage and other plan materials.