Prior Authorization Required

Prior authorization (PA) is required for many drugs listed in the formulary. Even when a medicine appears on the drug list, coverage under HealthPartners pharmacy benefits may be contingent on meeting PA criteria; if PA is not obtained the drug may not be covered.

• PA is used to confirm coverage criteria are met for plan benefits.
• When a product line shows the PA flag, providers must submit a prior authorization request before the drug will be covered at the plan’s preferred cost share.
• Failure to obtain PA may result in the claim being denied or the drug not being covered.

Step Therapy Requirement

Step therapy (ST) requires that specified alternative agents be tried first. If the required prior treatments have not been tried, a prior approval (or PA) is required before the requested medicine will be covered at the preferred copay/coinsurance.

• HealthPartners covers a step-therapy medicine only after required alternative(s) have been tried and documented.
• If step therapy is not completed, submit clinical rationale and prior authorization evidence to request coverage.
• Step/Program flags in the formulary indicate where ST applies and may trigger enhanced review.

Requirements, Quantity Limits & Denial Triggers

Quantity limits (QL), specialty (S), non-preferred (NP), oncology (ONC), opioid program (OP), enhanced (ENH) and other utilization flags on formulary lines can trigger additional review or denial if the requirements are not met.

• Requests above a listed QL will be reviewed for medical necessity and require documentation of diagnosis, alternatives tried, prior use, and evidence supporting the quantity requested.
• Many specialty and oncology agents are flagged S and/or ONC; absence of required specialty designation or PA may lead to denial.
• NP/OP/TD/ENH flags indicate program edits or enhanced review that may require additional documentation or PA.
• Exceeding QL or lacking required PA/NP/S documentation increases the risk of claim denial.

Documentation Expectations and Required Information

Provide supporting documentation with PA, QL exception, or step therapy override requests. Documentation should include diagnosis, prior therapies tried (dates and outcomes), dosing, pack size, quantity requested, and clinical rationale or evidence of efficacy and safety.

• Requests above a QL: include diagnosis, alternatives tried, previous use within QL, and evidence supporting requested quantity.
• For PA on oncology or specialty drugs: include oncology-specific documentation and any program-specific criteria referenced on the formulary line.
• When ST is applied: document prior medication trials and reasons for failure/intolerance.
• Age limits (AL) and other enrollment flags must be addressed in the documentation (e.g., Min 12 Years, Min 18 Years where noted).

Examples of PA-Listed Drugs and Common PA Triggers

Examples: numerous formulary entries show PA and related flags. Common examples include oncology and specialty oral agents (e.g., IBRANCE, VENCLEXTA, HARVONI, EPCLUSA), many antiepileptic medications (e.g., KEPPRA, NEURONTIN, ONFI), and multiple other agents across therapeutic classes. Review the formulary lines for PA, QL, S, NP, ONC, TD, and other flags.

• Formulary lines explicitly list PA and other requirement flags next to each presentation — check the Requirements / Limits column when prescribing.
• Some products additionally require specialty designation (S) and have specific QL entries (e.g., IBRANCE QL 21 per 28 days; VENCLEXTA QL per day and per 135 days).
• Antiepileptic and many high-cost agents frequently show PA and QL; prescribers must submit PA and supporting documentation for these classes.

Follow TD sequencing or secure authorization

TD (therapeutic direction) flags on some entries suggest sequencing or step requirements may apply; follow indicated therapeutic‑direction guidance or obtain authorization if sequencing requirements are unmet.

Adhere to NP/program routing for CNS/neurology drugs

Some CNS/neurology drugs carry NP or other program flags indicating special handling; when these flags appear, providers should follow the program routing and submit required documentation.

Try preferred alternatives or provide PA for NP/step edits

Products annotated with NP or PA; NP; QL (for example perampanel) imply step edits or non‑preferred pathways — try preferred alternatives or obtain prior approval with supporting clinical rationale.

Fill specialty/oncology medicines at specialty pharmacy

Specialty and oncology medicines must be filled at a specialty pharmacy; benefits and routing may differ from retail pharmacy coverage and specialty dispensing requirements must be followed.

Observe site‑of‑care restrictions for S‑flagged injectables

Some injectable or infusion products are flagged 'S' for site restrictions; these may require administration in infusion center, clinic, or hospital outpatient settings per the formulary entry.

Comply with OP/outpatient site restrictions when shown

OP or outpatient flags indicate site or outpatient program limits for particular formulations; follow the OP designation when present on the product line.

Use specialty pharmacy/infusion center routing for S‑designated products

Specialty products and certain neurologic injectables annotated 'S' require specialty pharmacy processing and may have specific quantity‑limit periods or administration site requirements.