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Prior Authorizations
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2020 Prior Authorizations

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.  Coming soon!

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

Abilify MyCite

Actemra Prefilled Syringe

Actimmune

Adempas

Ambrisentan

Armodafinil

Austedo

Bosentan

Botulinum Toxins

Cosentyx

Early Refill

Deferasirox

Dronabinol

Dupixent

Emflaza

Enbrel

Endari

Epidiolex

Esbriet

Fentanyl Citrate Transmucosal Lozenge

Filgrastim Agents

Forteo

H.P. Acthar Gel

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

Ledipasvir/sofosbuvir

Lidocaine Patches 

Long Acting Opioids

Lucemyra

Lyrica CR 

Mavenclad

Myalept

Nuedexta

Norditropin

Ocaliva

Ofev

Opsumit

Orencia

Orkambi

Part B vs D Drugs

Pegfilgrastim Agents

Praluent

Promacta

Ravicti

Regranex

Repatha

Revatio (sildenafil)

Sofosbuvir/velpatasvir

Stelara

Sympazan

Tadalafil

Testosterone Products

Tetrabenazine

Thalomid

Topical Retinoids

Uptravi

Vitrakvi

Xeljanz

Xifaxan

Xolair

Xospata

Xpovia

Xyrem

Zepatier