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2017 Prior Authorizations
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2018 Prior Authorizations

To be sure that certain medications are used appropriately, prior authorization (plan approval) may be required before prescriptions for these drugs can be filled. Prior authorization may be required for the following drugs and reasons:

  • Non-formulary medications or benefit exceptions required by medical necessity
  • All brand name medications when there is an A-rated generic version available
  • Medications and/or treatments if they are under clinical investigation
  • Medications prescribed for non-FDA approved uses
  • Prescriptions that exceed set plan limits (days' supply, quantity, cost)
  • New-to-market products
  • Medications that have treatment guidelines developed by the Health Partners Plans’ Pharmacy & Therapeutics Committee

Prior Authorization requests may be submitted by the member or the provider; however, supporting clinical information is usually needed from the provider. They can be faxed to 1-866-371-3239.

2018 Prior Authorization Forms

View the complete list of CMS-approved Prior Authorization criteria by plan by clicking on one of the links below:

The following forms are downloadable in PDF format.

Actemra Prefilled Syringe

Actiq

Adcirca

Adempas

Botox

Buprenorphine

Buprenorphine-naloxone Containing Products

Cosentyx

Early Refill

Enbrel

Epclusa

Esbriet

H.P. Acthar Gel

Harvoni

Hetlioz

High Risk 1st Generation Antihistamines

High Risk Butalbital Combinations

High Risk General

High Risk Non-Benzo Sedative Hypnotic

High Risk Non-Cox Selective NSAIDs

Human Chorionic Gonadotropin

Humira

Ingrezza Initial

Ingrezza Renewal

Juxtapid

Kalydeco

Kynamro

Letairis

Lidocaine (Lidoderm) Patch

Myalept

Neulasta

Neupogen

Norditropin

Nuvigil

Opsumit

Orencia

Orkambi

Oxycontin

Part B vs D Drugs

Praluent

Procrit

Promacta

Repatha

Ribavirin

Sildenafil

Sovaldi

Synagis

Thalomid

Tracleer

Uptravi

Xifaxan

Xolair

Zepatier

Zyvox (linezolid)

 

2017 Prior Authorizations

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