December 31, 2020
SUBJECT 2021 Q1 Drug Formulary Change Notification
PROVIDERS AFFECTED All providers
KEY POINTS • Hennepin Health is making several changes from the Q4 2020 drug formulary. • The changes apply to all Hennepin Health members. • The updated full drug formulary is available online. A printed copy can be obtained by calling Provider Services at 612-596-1036 (select option #2).
BACKGROUND We have made several changes to the drug formulary. These changes apply to Hennepin Health PMAP, MNCare and 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 (press option 2).
Effective 01/01/2021, these medications were added • Brilinta • Cellcept Suspension • Esomprazole capsule • Flector • Fluorometholone (Ophthalmic) • Humalog Cartridge • Humalog Junior Kwikpen • Humalog Pen • Humalog Mix Pen • Humulin 500U/M Pen • Prasugrel, add PDL designation • Prednisolone Acetate (Ophthalmic) • Revatio Suspension (Oral)
Effective 01/01/2021, these medications were added with a Medical Benefit (MB) indicator and require Prior Authorization (PA) • Adakveo • Advate • Alphanate • Benefix • Berinert Inj • Coagedex • Corifact Kit • Feiba NF • Hemofil-M • Humate-P Kit • Koate-DVI Kit • Koate-DVI Vial • Mononine Kit • Novoeight • Nuwiq • Profilnine SD • Tretten • Wilate • Xyntha Kit • Xyntha Solofuse Syringe Kit
Effective 01/01/2021, these medications were added and require PA • Droxia • Endari • Oxbryta
Effective 01/01/2021, these medications with were added and require Quantity Limits (QL) • Adderall XR, QL 1 cap/day; only one strength allowed per month • Concerta, QL 1 tab/day only one strength allowed per month • COVID-19 Vaccine Inj (Moderna), QL (1 dose/24 days; limit 2 fills/12 months) • COVID-19 Vaccine Inj (Pfizer), QL (1 dose/17 days; limit 2 fills/12 months) • Diclofenac Gel, removed as PDL, QL 100gm/30 days • Methylin Solution, QL 360mls/30 days
Effective 01/01/2021, these medications removed the PA requirement: • Ambrisentan (Oral) • Insulin Lispro Pen • Insulin Lispro Vial • Methylphenidate solution • Moxifloxacin (Ophthalmic) (Generic Vigamox) • Sevelamer Carbonate Tablet
Effective 01/01/2021, these medications removed the PA requirement and added QL: • Lansoprazole capsule, QL • Methylphenidate solution, add QL 360 mls/30 days
Effective 01/01/2021, these medications were removed: • Aggrenox • Amphetamine Salt Combo ER • Elidel • Glyset • Letairis (Oral) • Methylin chewable tablets • Methylphenidate CD • Methylphenidate chewable tablets • Methylphenidate ER (Generic Concerta) • Methylphenidate ER, 72 mg tablet • Novolin Pen OTC • Renagel • Vigamox
RESOURCES: • Hennepin Health Member Services: 612-596-1036 (press option 2) • 2021 Medicaid list of covered drugs (Formulary) – effective 01/01/21 (PDF) • Hennepin Health website: hennepinhealth.org