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2019 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.

You can also call us to make a request at 1-866-901-800 (TTY 711), or mail it to

Attention: Pharmacy Dept.
Health Partners Medicare
901 Market Street, Suite 500
Philadelphia, PA 19107

2019 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.

  • Health Partners Medicare members can request a prior authorization through our pharmacy portal

Actemra Prefilled Syringe

Actiq

Adcirca

Adempas (coming soon)

Aimovig

Armodafinil (Nuvigil)

Botox

Cosentyx

Early Refill

Emflaza

Enbrel

Endari

Epclusa

Esbriet

Exjade

Filgrastim Agents

Forteo

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

High Risk Skeletal Muscle Relaxants

Humira

Ingrezza

Intravenous Immune Globulin (IVIG)

Juxtapid

Kalydeco

Kynamro

Letairis

Lidocaine (Lidoderm) Patch

Linezolid (Zyvox)

Lucemyra

Lyrica CR 

Lyrica IR (coming soon)

Myalept

Nuedexta

Neulasta (coming soon)

Norditropin

Ocaliva

Ofev

Opsumit

Orencia

Orkambi (coming soon)

Oxycontin

Part B vs D Drugs

Praluent

Procrit

Promacta

Ravicti

Repatha

Sildenafil (Revatio)

Thalomid (coming soon)

Tracleer

Uptravi (coming soon)

Xifaxan

Xolair (coming soon)

Xyrem

Zepatier (coming soon)

 

 

2018 Prior Authorizations