CurrentHealthPartnersPolicy N/A

Commercial 2026 Formulary Prior Authorization and Step Therapy Criteria (partial list)

Formulary prior authorization (PA) and step therapy (ST) criteria listing for many prescription drugs specifying per-product PA/ST rules (e.g., reserved uses, required trials of preferred alternatives, documented allergy to generics, and links to detailed PA criteria).

Policy Summary

PayerHealthPartners

PolicyCommercial 2026 Formulary Prior Authorization and Step Therapy Criteria (partial list)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for the listed products; providers must submit clinical justification per the product-specific PA criteria or linked PA documents.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — the policy lists product-specific prior authorization and step therapy criteria but has no material change noted.

manyProducts listed in this part

multipleProducts referencing external PA documents

multipleEntries requiring opioid attestation

1Special-case products with numeric thresholds

Withdrawn / not eligible examples

Coverage Summary

General PA / Step Therapy patterns in this section

General PA / Step Therapy patterns in this section:

ANY of the following

Reserved for patients with a documented allergic reaction to the equivalent generic or preferred product.
Reserved for FDA‑approved indications only (coverage limited to labeled use).
Requires inadequate response to preferred alternatives — commonly two failed trials of preferred products before coverage of the non‑preferred agent is allowed.
Product‑specific restrictions such as age/weight limits, formulation‑specific use (e.g., sprinkle vs capsule), or site‑of‑care requirements.
Some complex biologic, oncology or specialty drugs require submission of and adherence to detailed external PA documents (link provided in the master list).
Certain agents are reserved for cases with documented clinical need such as documented compliance concerns (e.g., Abilify MyCite) or when alternatives are contraindicated.
When a preferred biosimilar exists, coverage of the brand product is often reserved only for patients with documented allergic reaction or intolerance to the biosimilar.
Step therapy policies require trial and failure of specified preferred medications; exceptions are considered for contraindications or intolerance documented in the medical record.

Per-product Prior Authorization / Step Therapy Criteria (alphabetical entries)

Per‑product entry patterns and examples (alphabetical). Preserve nested ANY logic and examples.

Per‑product PA/ST entries (examples list)

Examples
- Generic allergy example: ABILIFY: Reserved for patients with a documented allergic reaction to the equivalent generic
- Multi‑criterion example: ABILIFY MYCITE: Reserved when ALL three criteria are met: (1) Reserved per FDA indications; (2) For patients with documented compliance concerns with oral therapy; (3) When injectable therapy is contra‑indicated
- Specific indication + dose limit:

Step Therapy (ST) and Standard Templates

Most entries follow one of these standardized criteria templates

Surface the common standardized templates used repeatedly (allergy template, FDA‑indication + step failures, specialist requirements, opioid attestation).

Standardized PA templates

Allergy template: Reserved for patients with a documented allergic reaction to the equivalent generic
Step failures template: Reserved for FDA‑approved indications, for patients with an inadequate response to two preferred alternatives or with medical contraindications to their usetwo preferred alternatives
Specialist prescribing example: Prescribing by a specialist (examples: DALFAMPRIDINE ER requires neurologist and attestation of walking difficulty; CAYSTON requires CF center prescribing and annual CF visit documentation)

Provider Actions & Operational Requirements

Prior Authorization

Prior Authorization Required per Product

Prior authorization is required for each listed product and must be requested separately for the specific drug per the product‑specific criteria. Submit the member’s clinical justification that demonstrates the applicable reservation condition (for example: documented allergy to the generic, prior trials of preferred alternatives, FDA‑approved indication, specialist prescribing, or other product‑specific clinical requirements). Follow any linked HealthPartners PA criteria when the drug entry includes a URL.

Submit clinical justification per the product‑specific PA criteria (e.g., allergy documentation, prior therapy trials, specialist notes).
If the listing includes a HealthPartners PA link, follow that linked PA document and submission instructions.

Documentation Required

Document Prior Therapies, Allergies, and Specialist Care

Applicable Codes & External Criteria Links

Numeric Thresholds & Notable Exceptions

Per-product Prior Authorization Criteria (alphabetical: M - O)

Fentanyl family and other opioid entries summarized as explicit AND nodes combining provider attestation and prior trial where applicable.

Fentanyl & opioid PA (explicit conditions)

Provider attestation requirement: Provider must attest that therapy is being managed per standard opioid prescribing guidelines
applies to long‑acting opioids
Prior short‑acting opioid trial: Patient must have had an inadequate response to a recent adequate trial (minimum 30 days continuous) with a short‑acting opioid prior to long‑acting opioid approvalminimum 30 days continuous

Background

Prior authorization and step therapy are used to ensure appropriate, evidence‑based use of certain formulary medications and to require trials of preferred, lower‑cost alternatives before coverage of non‑preferred agents. Per‑product entries are organized alphabetically; each entry shows a one‑line reservation (e.g., 'Reserved for FDA‑approved indications' or 'Reserved for documented allergic reaction to equivalent generic') or provides a link to a detailed PA criteria PDF when more specific clinical or documentation requirements apply.

Definitions

Definitions used in the listing: Reserved — indicates the product is subject to prior authorization and will be covered only when specified conditions are met.

Inadequate response — clinical failure or intolerance to specified preferred alternatives as documented by the provider.

Provider attestation — a clinician‑signed statement required for certain medications (for example, long‑acting opioids) confirming adherence to prescribing standards and prior trials.

Preferred alternatives — lower‑tier or formulary‑preferred medications expected to be tried before non‑preferred agents are approved.

Step Therapy (ST) — a utilization management protocol where preferred medications must be tried before coverage of non‑preferred alternatives; details and lookback periods are provided in linked HealthPartners ST/PA documents.

Prior Authorization Criteria — product‑specific clinical and administrative criteria (often on a linked HealthPartners webpage or PDF) that must be met for coverage.

STEP CRITERIA — lookback or prior‑use requirements that the member must meet (e.g., prior use of a preferred product within the previous 12 months) before the non‑preferred product will be covered; providers may request approval or exceptions per the linked criteria.

Clinical Evidence

For clinical justification, literature documentation requirements, and the detailed clinical criteria supporting coverage decisions, refer to the product‑specific PA PDFs and coverage pages linked in each drug entry (multiple external HealthPartners PDFs and coverage criteria URLs are referenced throughout the listing).

Revision History

noteLatest

Document compiled from HealthPartners formulary PA/ST listings; no dated revision entries included in this part

Policy Summary

PayerHealthPartners

PolicyCommercial 2026 Formulary Prior Authorization and Step Therapy Criteria (partial list)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for the listed products; providers must submit clinical justification per the product-specific PA criteria or linked PA documents.

SourceLink

On This Page

ACTIMMUNE: Reserved for named indications AND when prescribed up to recommended maximum dose of 50 mcg/m three times weekly

50 mcg/m three times weekly

Common generic‑allergy pattern: Many branded products (eg ADDERALL, CONCERTA, etc.) reserved for patients with a documented allergic reaction to the equivalent generic

FDA‑indication + two‑preferred failures: Multiple products: 'Reserved for FDA‑approved indications, for patients with an inadequate response to two preferred alternatives or with medical contraindications to their use.'two preferred alternatives

Preferred dosage form exceptions: Some products reserved for inadequate response to a preferred dosage form or contraindication to its use (examples noted inline)

Literature documentation required: Some exceptions require documentation in the medical literature of clinical benefits over preferred alternatives (examples shown inline)

External PA link examples: Some products reference an external detailed PA PDF or webpage (HealthPartners links) for full criteria (examples shown inline)

Not medically necessary examples: Some products are noted as not medically necessary with rationale (example: AGAMREE) when insufficient evidence of superiority exists

Selected product-specific criteria (explicit in this part)

Selected explicit one‑line product criteria appearing in this excerpt. Preserve leaf nodes and provided links/notes.

Per‑drug one‑line criteria (selected)

BESPONSA: PA criteria provided at HealthPartners coverage‑criteria page
https://www.healthpartners.com/public/coverage-criteria/?hideProduct=false&letter=All&keywords=&product=&priorAuthRequired=&category=Pharmacy
BESREMI: PA criteria provided at HealthPartners PDF
https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/entry_209299.pdf
BETAINE ANHYDROUS: Reserved for FDA‑approved indications (severe hyperhomocysteinemia) and inadequate response to diet and vitamin supplementation
BETAMETHASONE VALERATE: Reserved for patients with an inadequate response to a formulary topical corticosteroid in a liquid formulation
BIMZELX / BIMZELX AUTOINJECTOR: See HealthPartners PDF link for PA criteria
https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/entry_209231.pdf
BONJESTA: Reserved for patients with a documented allergic reaction to a preferred generic (preferred products include doxylamine/pyridoxine)
BUPRENORPHINE (long‑acting): BUPRENORPHINE (long‑acting formulations): Long‑acting opioids require provider attestation and prior trial (minimum 30 days) of a short‑acting opioidminimum of 30 days continuous short‑acting trial
BUTRANS: (1) Reserved for patients with a documented allergic reaction to the equivalent generic; (2) Long‑acting opioid attestation required per opioid guidelinesminimum of 30 days continuous short‑acting trial
REPATHA example: REPATHA: Step criteria requiring use of a generic statin within previous 12 months (provider may request approval if tried earlier)12 months lookback
GATTE X (Gattex): Gattex: Reserved for adult short bowel syndrome patients dependent on parenteral nutrition >=4L daily, dependent ≥1 year and ≥3 days/week; initial approvals 3 months; reauthorizations up to 1 year with documented reduction in parenteral nutrition; doses up to 5 mg daily approved>= 4L daily; >=1 year; >=3 days/week; up to 5 mg daily

General Prior Authorization Patterns (applies per listed drug unless a specific link or exception provided)

Common templated PA language used repeatedly across the formulary — reserved phrases and special requirements.

Template language collection

Allergy template: Reserved for patients with a documented allergic reaction to the equivalent generic (or preferred biosimilar/brand)
FDA indication + prior failures template: Reserved for FDA‑approved indications, for patients with an inadequate response to two preferred alternatives or with medical contraindications to their usetwo preferred alternatives
Specialist prescribing template: Prescribing by or in consultation with specified specialists and documentation (examples: cystic fibrosis center for inhaled antibiotics; infectious disease for select antifungals)
Opioid attestation template: Long‑acting opioids require a provider attestation that therapy is managed per standard opioid prescribing guidelines and a minimum 30‑day prior trial of a short‑acting opioidminimum 30 days

Per-product Prior Authorization Criteria (alphabetical: M - O)

Per‑product criteria for products in the M–O alphabetical range; preserve numeric thresholds and examples.

M–O per‑product examples

MORPHINE SULFATE ER CAPSULE/TABLET: MORPHINE SULFATE ER CAPSULE: (1) Reserved after two preferred products tried/failed or contraindicated; (2) Long‑acting opioid provider attestation required per opioid guidelinesminimum 30 days short‑acting trial for attestation
METHADOSE 40 MG TABLET DISPR: Long‑acting opioid — provider attestation required per opioid guidelinesminimum 30 days short‑acting trial
METHITEST / TESTOSTERONES: METHITEST/METHYLTESTOSTERONE/NATESTO/TLANDO/UNDECATREX: Reserved for patients with (1) documented testosterone deficiency <300 ng/dL and inadequate response or contraindication to two or more preferred alternatives; OR (2) diagnosis of gender dysphoria per plan benefits with inadequate response/contraindications to two or more preferred productstestosterone < 300 ng/dL; two preferred alternatives
MOUNJARO / OZEMPIC / TRULICITY: MOUNJARO, OZEMPIC, TRULICITY: Reserved for members with type 2 diabetes (product‑specific)
MOVANTIK / RELISTOR: MOVANTIK: Reserved for opioid‑induced constipation after inadequate response to laxative therapy; RELISTOR reserved for opioid‑induced constipation after inadequate response to Symproic and Movantik
GAT T EX (Gattex) numeric thresholds: Gattex: Adult short bowel syndrome with parenteral nutrition >=4L daily, dependent >=1 year and >=3 days/week; initial 3 months; reauthorization up to 1 year with reduction in parenteral nutrition; doses up to 5 mg daily approved>=4L daily; >=1 year; >=3 days/week; up to 5 mg daily

DALFAMPRIDINE initial 6 months; CAYSTON initial 12 months

Opioid attestation template: Long‑acting opioids: provider attestation of opioid management per guidelines and prior adequate short‑acting opioid trial (minimum 30 days)minimum 30 days

Many products follow one of several recurring PA criteria patterns

Recurring PA patterns focusing on required step failures (often 2) and lookback / specialist / age/weight rules.

Recurring PA patterns (step/specialist/age/weight)

Two‑preferred failure common pattern: Reserved for FDA‑approved indications for patients with an inadequate response to two preferred alternatives or with medical contraindicationstwo preferred alternatives
Step lookback / prior‑use examples: Step edits frequently require evidence of prior use within a defined lookback (examples: 12 months, 365 days) or provider may request exception if prior trial was earlierexamples: 12 months, 365 days
Specialist prescriber requirements: Certain agents require prescribing by/consult with specialists (eg Infectious Disease for NUZYRA; Neurology for DALFAMPRIDINE ER); documentation required for renewals
Age / weight limits: Some products have explicit pediatric/weight restrictions (example: Gilenya 0.25 mg capsule reserved for pediatric patients >10 years and <40 kg; Tascenso ODT age/weight rules)Gilenya pediatric >10 yrs and <40 kg; Tascenso >=10 yrs and <=40 kg

Step Therapy (ST) Criteria — selected products

Select ST examples that include explicit step lookback or prior‑use requirements; preserve ANY operator where used.

Step Therapy (selected products)

ALTABAX step lookback: ALTABAX: Covered if generic mupirocin ointment used within previous 3 months; if tried earlier but not within 3 months, provider may request approval3 months lookback
CARBIDOPA‑LEVODOPA ER lookback: CARBIDOPA‑LEVODOPA ER: Covered if carbidopa/levodopa ER capsule or generic used within previous 12 months; provider may request approval if prior use was earlier12 months lookback
DEXCOM / FREESTYLE LIBRE insulin requirement: DEXCOM & FREESTYLE LIBRE: Coverage links provided; explicit requirement: must be using insulin in the previous 6 monthsinsulin use within prior 6 months
https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/entry_241862.pdf
REPATHA statin prior use: REPATHA: Covered if a generic statin medication used within the previous 12 months; provider may request approval if prior trial was earlier12 months lookback
TRINTELLIX antidepressant prior use: TRINTELLIX: Covered if a generic antidepressant used within the previous 12 months; provider may request approval if prior trial was earlier12 months lookback
ZOLPIDEM ER prior use: ZOLPIDEM TARTRATE ER: Covered if generic zolpidem regular release used within previous 12 months; provider may request approval otherwise12 months lookback
EUCRISA / OPZELURA / VTAMA / ZORYVE topical lookback: EUCRISA/OPZELURA/VTAMA/ZORYVE: Covered if generic tacrolimus ointment or pimecrolimus cream used within previous 12 months (365 days for some); provider may request approval if prior trial was earlier12 months or 365 days lookback

Document prior therapy trials, allergic reactions, and specialty care in the medical record to support PA. Specifically: document prior trials or contraindications to preferred agents as required; record any documented allergic reaction to an equivalent generic; include specialty consult notes when the drug requires specialist involvement. For long‑acting opioid requests include the provider attestation required by the opioid rules.

Long‑acting opioid attestation per opioid guidelines (provider attestation that therapy is managed per standard opioid prescribing guidelines and that the patient had a recent adequate trial — minimum 30 days — of a short‑acting opioid).
Testosterone products: document testosterone level < 300 ng/dL or diagnosis of gender dysphoria per plan benefits and prior inadequate response/contraindications to two or more preferred alternatives.
Cystic fibrosis specialty requirements (e.g., CAYSTON, TOBI/Tobramycin) and other specialty prescriber documentation — see product entries for specialist/center requirements.

Note

Follow Linked Product-specific PA Criteria

When a drug entry includes a HealthPartners URL or PDF link, follow the linked product‑specific prior authorization criteria and submission instructions rather than relying on the one‑line summary. Many product entries embed exact PDF links or filenames — providers should open and use the linked PA document for required forms, thresholds, and supporting evidence.

Examples of exact linked PA PDFs referenced in entries: entry_209299.pdf
iron-chelating-agents.pdf (deferasirox/deferiprone/JADENU)
camzyos-myqorzo.pdf (Camzyos / Myqorzo)

Billing Rule

Quantity, Duration and Reauthorization Rules

Review quantity, duration, and reauthorization requirements in the product entry; some specialty agents have time‑limited initial approvals and specified reauthorization conditions. Note initial approval windows and required evidence at renewal for continued coverage.

Gattex — initial approval 3 months; reauthorization may be provided up to 1 year with documented reduction in parenteral nutrition volume; doses up to 5 mg/day approved.
Pulmozyme — initial approval 12 months; renewals annually with documentation patient seen at CF treatment center within last 12 months and medication effectiveness.
Nexletol / Nexlizet — approvals given for 1 year; reauthorization requires documentation/attestation of LDL cholesterol reduction.

Denial Risk

Safety Advisories / Do Not Prescribe

Be aware of safety advisories and plan directives that instruct prescribers to stop using certain products. For drugs with explicit 'stop prescribing' guidance, transition patients per the referenced disease‑specific policy; failure to comply with safety guidance may affect coverage.

Ocaliva — HealthPartners instructs health care professionals to stop prescribing Ocaliva (see Primary Biliary Cholangitis policy).
Oxbryta — HealthPartners instructs health care professionals to stop prescribing Oxbryta per plan guidance.

Documentation Required

Specialty Prescribing & Supporting Tests

For specialty anti‑infectives and inhaled agents used in cystic fibrosis, include the required supporting tests and specialty prescribing documentation with the PA. Verify the prescriber specialty and submit any mandated laboratory or microbiology results.

NUZYRA — reserved when: FDA‑approved indication; prescribing by or consult with Infectious Disease; inadequate response to standard treatments. Culture and sensitivity results are required.
CAYSTON and TOBRAMYCIN (ampules/paks) — use limited to cystic fibrosis patients with Pseudomonas aeruginosa, prescribed and managed by specialists at a CF treatment center; initial approvals 12 months and renewals annually with documentation of CF center visit within last 12 months and medication effectiveness.
CAYSTON/TOBI entries require CF center management and documentation of culture/sensitivity and annual specialist follow‑up.

Fentanyl family specific uses:

Fentanyl products reserved for failure of preferred fentanyl patches, breakthrough cancer pain in opioid‑tolerant patients after two preferred product failures, or per FDA indication with two preferred failures

two preferred failures where specified

Some drugs are withdrawn or not eligible for coverage (example: Relyvrio is not eligible for coverage and was withdrawn from the market as of 4/4/2024). Providers should verify current availability or coverage status by consulting the linked HealthPartners coverage pages or product PDFs before requesting PA.