HealthPartners pharmacy Prior Auth & Coverage

General PA/Step Therapy Conditions

Common PA/ST coverage conditions noted in the listed entries

General PA/ST conditions: Coverage for many non-preferred medications requires (1) FDA‑approved indication where specified; AND (2) documented inadequate response to one or more (often two) preferred alternatives or a documented medical contraindication or allergic reaction to preferred products; OR (3) compliance with specific criteria referenced in linked product‑specific prior authorization documents.often 2 preferred alternatives

Specific drugs have individualized criteria referenced via links or inline statements

General step therapy/prior authorization criteria

Covered when ALL of the following are met (general template used across products):

General ST/PA requirements: 1) Patient has inadequate response to the specified number of preferred products (commonly one or two) OR 2) patient has a medical contraindication or documented allergy to preferred alternatives; some products require documentation in the medical literature of clinical benefit over preferred alternatives or adherence to FDA‑approved indications/criteria.as specified per product

Individual product entries may modify number of required failures, require provider attestation, or direct to product‑specific PA documents.

General coverage conditions

Coverage for each listed product is subject to one or more of the following conditions:

Allowance conditions: Coverage reserved when patient meets at least one of: documented allergic reaction to equivalent generic; inadequate response to one or two preferred alternatives (product‑specific); or medical contraindication to preferred options.varies by product

Applies across many listed drugs (see individual entries).

Aztreonam inhalation (CAYSTON)

CAYSTON-specific coverage

CAYSTON criteria: (1) Patient has cystic fibrosis with documented Pseudomonas aeruginosa; (2) prescribed and managed by specialists from a cystic fibrosis treatment center; (3) quantity limited to one 28‑day package per month; (4) initial approval provided for 12 months; (5) renewals require documentation of a CF center visit within the last 12 months and demonstration of continued effectiveness.1 x 28‑day package/month; initial 12 months

Missing any element may result in denial.

Cholbam (cholic acid)

Cholbam-specific coverage

Cholbam criteria: (1) Prescribed by an appropriate specialist; (2) indication is bile acid synthesis disorders due to single enzyme defects or adjunctive treatment in select peroxisomal disorders with liver manifestations; (3) prescribed dose is verified by patient weight (typical dosing ≤15 mg/kg/day; specific contexts may allow other dosing per product language); (4) initial authorization provided for 6 months with reauthorization contingent on improvement in liver function and demonstration of ongoing efficacy for annual renewal.≤15 mg/kg/day (usual)

Weight required to verify dosing and reauthorization evidence of liver improvement.

Recurring coverage criteria and notable product-specific requirements

Coverage reserved or limited under the following recurring conditions:

All common reservation reasons: Coverage is commonly reserved for: documented allergic reaction to the equivalent generic; inadequate response to one or more preferred alternatives (frequently two); medical contraindication to preferred options; FDA‑approved indication restrictions; or specialist prescribing when specified.varies by product

This node summarizes repeated criteria across listed products.

CYSTADROPS/CYSTARAN specific: Prescribing by a specialist AND diagnosis of cystinosis; initial approval for three months; renewals require slit‑lamp exam documentation of clinical effect and may be approved up to one year.

From product entries for cystinosis treatments.

DALFAMPRIDINE ER specific: Diagnosis of multiple sclerosis AND currently able to walk 25 feet AND physician attestation of walking difficulty AND prescribing by a neurologist AND dose at or below FDA‑approved 10 mg twice daily; initial approval 6 months with documented ambulation improvement required for continuation to one year and annual thereafter for responders.

EMSAM — antidepressant step requirements

Examples of explicit drug-specific criteria found in this excerpt

EMSAM restriction: Covered only for patients with an inadequate response to at least three SSRIs AND at least one SSNRI AND at least one other antidepressant (e.g., bupropion, mirtazapine, phenelzine, tranylcypromine), OR for patients previously stable on EMSAM.trial counts specified

See product entry for exact trial classes and counts.

Long-acting opioid authorization

Opioid-specific requirement

Long-acting opioid attestation: Long‑acting opioid products require a provider attestation that opioid therapy is managed per standard opioid prescribing guidelines, including documentation of a prior adequate trial of a short‑acting opioid (minimum 30 days continuous use).>=30 days

Missing attestation or prior trial documentation may result in denial.

General step therapy / PA rule

Common plan stance for many listed drugs

General reserved criteria: Medication is commonly reserved for patients with inadequate response to two preferred alternatives, or with documented allergy or medical contraindication to preferred/generic options; some agents require literature support or specialist prescribing per linked PA criteria.often 2 prior failures

Refer to product‑specific PA links for full requirements.

General coverage conditions (per-product variations)

Coverage for listed drugs applies under one of the following documented conditions as stated per product

Allergen/generic exception: Coverage reserved when patient has a documented allergic reaction to the equivalent generic or brand as explicitly stated in many product entries.documented allergic reaction

Common single‑agent exception across entries.

Step therapy failure: Coverage reserved when patient has an inadequate response to two preferred alternatives (product‑specific), or when a medical contraindication to preferred products exists; documentation of clinical benefit over preferred alternatives may be required for some products.failure to 2 preferred products or medical contraindication

Common across multiple entries.

FDA‑approved indication with external criteria: Some agents are covered only for FDA‑approved indications and require adherence to detailed prior authorization criteria available at the HealthPartners links provided in the product line.

Coverage patterns (I–L)

Coverage/authorization generally follows one of these patterns depending on product:

Coverage patterns: 1) Reserved for FDA‑approved indications (may require failure of preferred alternatives); 2) Reserved for patients with documented allergic reaction to equivalent generic; 3) Reserved for patients with inadequate response to preferred dosage form or one/two preferred alternatives; 4) Some products refer to product‑specific PA PDFs for full criteria.

Summarized from I–L product segment.

General Step/PA criteria (L–M list)

Covered when meeting per-product PA criteria:

General step therapy requirement: Product is often reserved for FDA‑approved indications and requires inadequate response to two preferred alternatives or documented medical contraindication to their use; some products deviate and may require one failed alternative or a documented allergy.inadequate response to two preferred alternatives

External PA links clarify deviations.

Long-acting opioid attestation

Long-acting opioid coverage conditions:

Long-acting opioid attestation: Provider attestation required that opioid therapy is being managed per standard opioid prescribing guidelines, including evidence of a prior adequate trial of a short‑acting opioid (minimum 30 days continuous use) before authorizing long‑acting formulations.30 days

Applies to listed long‑acting opioid products (see entries).

Allergy exceptions

Allergy/generic substitution exceptions:

Allergic reaction to equivalent generic: Coverage is allowed when there is a documented allergic reaction to the equivalent generic or biosimilar for several brand products.documented allergic reaction

Multiple entries include this exception (brand covered only with documented allergy).

Common approval condition groups

Coverage reserved patterns observed in this excerpt:

Allergen/generic exception: Many products are reserved for patients with a documented allergic reaction to the equivalent generic or biosimilar.

Examples appear across multiple product lines.

Failure of preferred therapies: Multiple products require inadequate response to two (or sometimes three) preferred alternatives before non‑preferred coverage is allowed.

Examples include minocycline ER and selected NSAID formulations.

Specialty prescribing or documentation: Some specialty agents require prescribing by or consultation with a specialist and supporting documentation (e.g., culture results, specialist visit notes, weight for dosing).

See product entries for details.

Duration-limited coverage

Time-limited approvals

NUPLAZID initial and continuation: Initial approvals limited to 3 months; continuation up to 12 months requires medical chart documentation of improvement.3 months initial; up to 12 months continuation

Example of duration‑limited product in the list.

Common reserved coverage criteria (O–P products)

Covered only when at least one of the following reserved conditions is met (as specified per product):

Reserved conditions: (1) Documented allergic reaction to the equivalent generic; (2) Inadequate response to two preferred alternatives (or three for certain products); (3) Inadequate response to preferred dosage form or clinical contraindication to preferred options; (4) FDA‑approved indication restrictions; (5) For long‑acting opioids: failed adequate short‑acting trial and provider attestation of guideline‑concordant opioid management.as stated per product

Individual product entries may require additional documentation or link to product‑specific PA criteria.

Two-preferred-failures rule

Covered when specified programmatic conditions are met (examples extracted):

Two‑preferred‑failures rule: Coverage allowed when the patient has had an inadequate response to two preferred alternatives OR has medical contraindications to preferred options; documentation of clinical benefit over preferred alternatives may be required for some products.failure of 2 preferred alternatives

Common programmatic rule across many entries.

Allergic reaction exception

Allergic-exception coverage:

Allergy exception: Coverage permitted when there is a documented allergic reaction to the equivalent generic or preferred alternative as explicitly stated for the product.documented allergic reaction

This exception appears in many product entries.

Specialist-managed coverage

Specialist-managed or site-specific coverage:

Pulmozyme (cystic fibrosis): Prescribed and managed by specialists from a cystic fibrosis treatment center; initial approvals for 12 months with annual renewals requiring documentation of a CF center visit within the last 12 months and evidence of medication effectiveness.annual specialist visit

Site‑of‑care and renewal documentation required.

General coverage logic (R–S section)

Coverage for listed R–S drugs is provided under specific conditions as stated per product entry; common patterns across entries include:

Common PA/Step conditions: Coverage requires one or more of: documented allergic reaction to an equivalent generic; inadequate response to one or two preferred alternatives; medical contraindication to preferred alternatives; specialist prescribing when indicated; or use for FDA‑approved indications with additional documentation.varies by product

Individual product lines list exact requirement (see product‑specific line).

Per-product coverage qualifiers (segment)

Per-product coverage qualifiers in this segment (T- through TR- products):

Per-product qualifiers: Each listed product includes a short qualifier such as: reserved for documented allergic reaction to the equivalent generic; reserved for inadequate response to one or more preferred products or dosage forms; reserved for FDA‑approved indications only; or refer to an external detailed PA document.

Examples provided in product lines (T–TR range).

Examples with specific requirements: Examples include tobramycin inhalation — reserved for CF patients with Pseudomonas and specialist management plus quantity/renewal rules; tramadol ER — requires provider attestation of opioid management and prior adequate IR trial; TAPENTADOL ER — requires failure of two preferred products or documented contraindication.

Representative examples from this segment.

General product coverage patterns

Coverage is governed by product-specific prior authorization criteria; common patterns in this excerpt include:

Common authorization conditions: A product may be covered if ONE of the following applies: (1) Reserved for FDA‑approved indications with inadequate response to two preferred alternatives or medical contraindication; OR (2) Reserved for patients with documented allergic reaction to the equivalent generic; OR (3) Covered per detailed product‑specific PA criteria linked at HealthPartners URLs; OR (4) Requires prescribing by or consultation with a specialist for select drugs.

Patterns observed across multiple product entries.

VIBERZI initial and continuation criteria

VIBERZI-specific criteria

VIBERZI initial coverage: (1) Prescribing by gastroenterology; AND (2) diagnosis of irritable bowel syndrome with diarrhea; AND (3) trial and failure of conventional therapies including loperamide or diphenoxylate/atropine, a tricyclic antidepressant, and antispasmodics if painful symptoms present; AND (4) symptoms cause significant disability (hospitalizations, missed work, or restriction of daily activities).initial approval limited to 1 month

Continuation to one year requires documented significant positive response described in records.

VISTOGARD coverage

VISTOGARD coverage conditions

VISTOGARD indications: (A) Use following fluorouracil or capecitabine overdose per FDA‑approved 20‑dose regimen; OR (B) treatment of early‑onset, severe or life‑threatening toxicity affecting cardiac or CNS and/or early‑onset unusually severe adverse reactions within 96 hours following end of administration, when used per FDA 20‑dose regimen.approvals for 20 doses only

Approvals not granted for non‑emergent treatment of adverse reactions that could diminish chemotherapy efficacy.

Per-product PA or ST statements (excerpt)

Coverage or restriction statements shown exactly as 'PRIOR AUTHORIZATION CRITERIA =' or 'STEP CRITERIA =' for each listed product.

Products with external PA criteria link: Many products list a direct HealthPartners URL for detailed prior authorization criteria (see product‑specific link).

Providers should follow linked PA documents when present.

Products 'Reserved' for limited use: Several products are 'Reserved for FDA‑approved indications' or 'Reserved for patients with a documented allergic reaction to the equivalent generic' or 'Reserved for patients with an inadequate response to preferred alternatives' per the entry.

Common reservation phrasing across V–Z list.

Explicit step therapy rules (examples): Altabax: covered if generic mupirocin ointment used within prior 3 months; Carbidopa‑levodopa ER: covered if carbidopa/levodopa used within prior 12 months; Dexcom/FreeStyle Libre: require insulin use in prior 6 months; Eucrisa/Opzelura: require prior tacrolimus or pimecrolimus within prior 12 months (Opzelura: 365 days).

Concrete step examples from STEP CRITERIA lines.

Agamree is designated not medically necessary by HealthPartners because the evidence does not establish superiority to less costly alternatives. Requests for Agamree will not meet coverage unless the plan’s medical necessity criteria are satisfied or the designation is changed by HealthPartners.

Certain products in this drug-list are limited to FDA‑approved indications only. Coverage for these products is reserved to those approved indications and will require adherence to any product‑specific prior authorization criteria referenced in the entry.

Many listed agents are reserved for patients with a documented allergic reaction to the equivalent generic or for patients who have an inadequate response to preferred alternatives. When this exception is cited, providers must document the allergic reaction or the prior trials/failures of preferred products per the product’s PA/step criteria.

Deflazacort (including EMFLAZA and related brands) is considered not medically necessary because there is insufficient evidence of superiority to much less costly alternatives. The brand product is reserved only for members with a documented allergic reaction to the equivalent generic.

If a product’s reservation conditions are not met—for example, there is no documentation of allergy to the generic, no documented trial/failure of required preferred products, or required specialist prescribing or external PA documentation is absent—the request may be denied and coverage will not be provided at the plan benefit level.

The plan’s rationale for listing Deflazacort brands (e.g., JYMBEE/KYMBEE/EMFLAZA) as not medically necessary is that available evidence does not demonstrate superiority over substantially less costly alternatives. Brand formulations may only be considered if there is a documented allergic reaction to the generic equivalent.

Some specialty or trial‑aligned drugs are reserved for patients who meet clinical trial inclusion/exclusion criteria or specific guidance described in the product entry. These products may require adherence to external PA documents and supporting clinical documentation to establish eligibility.

HealthPartners advises that providers should stop prescribing Ocaliva; patients and caregivers should contact their clinician about alternative treatments. See the Primary Biliary Cholangitis policy for details and applicable coverage instructions.

Health care professionals are advised to stop prescribing Oxbryta. Members and caregivers should contact their provider about discontinuation and selection of an alternative therapy as appropriate.

Relyvrio has been withdrawn from the market and is therefore not eligible for coverage through HealthPartners as of 4/4/2024.

Several products in the list are covered only for FDA‑approved indications; use outside those indications will not be covered unless separate prior authorization criteria explicitly allow off‑label coverage.

Approvals for VISTOGARD are limited to the FDA‑approved 20‑dose regimen for fluorouracil or capecitabine overdose or for specified early‑onset, severe toxicities; approvals will not be granted for non‑emergent treatment of adverse reactions related to these chemotherapies because it may reduce chemotherapy efficacy.

Coverage will not be provided for non‑emergent treatment of adverse reactions to fluorouracil or capecitabine (e.g., outside the FDA‑approved emergency indications), consistent with the product‑specific PA language that reserves VISTOGARD only for overdose or early‑onset severe toxicities.

Provider Requirements, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for many products listed below or referenced on HealthPartners coverage pages. Providers should submit the appropriate HealthPartners prior authorization (PA) request and any supporting documentation indicated in linked PA criteria PDFs. Coverage is contingent on meeting PA and step-therapy (ST) prerequisites; failure to document required prior trials, contraindications, or allergies may result in denial.

Many entries link to product- or condition-specific PA criteria on HealthPartners web pages or PDF documents — submit the referenced PA documentation with the request.
When a product is reserved for use only after inadequate response to preferred alternatives, provide documentation of trials (dates, agents, durations) or a medical contraindication/allergy.
Allergic-reaction exception: several brand or non-preferred products are covered only when there is a documented allergic reaction to the equivalent generic or preferred alternative; provide chart evidence.
Two-preferred-failures requirement: numerous products require documented inadequate response to two preferred alternatives before approval.
External PA documents and product-specific criteria: follow the instructions and documentation fields in the linked PDFs (culture/sensitivity reports, specialist consults, lab results, etc.).

Prior Authorization

Prior authorization and duration limits (e.g., DIFICID)

DIFICID (fidaxomicin) and other C. difficile–specific agents may have duration limits specified in the PA criteria. For DIFICID, approvals are limited to 10 days for treatment of C. difficile infection unless otherwise noted in the PA document.

Observe the specified maximum treatment duration when requesting PA for C. difficile agents.
If longer therapy is requested, include clinical justification and supporting documentation per linked criteria.

Prior Authorization

PA required or coverage reserved

Many products are either PA-required or coverage is reserved (e.g., for failures of preferred therapy, documented allergy, or specific FDA indications). Providers must determine if PA is required and, when reserved, supply the required trial/failure or allergy documentation.

Examples: non-preferred branded, specialty, or long-acting formulations frequently require PA; some agents are limited to FDA-approved indications only.
If a product is listed as “reserved” provide medical record evidence of prior trials, failures, contraindication, or allergy as applicable.

Documentation Required

Prior authorization references and external criteria

PA requirements often reference external HealthPartners criteria. Providers should review and follow the linked coverage criteria documents and provide the specific documentation requested (e.g., lab results, culture/sensitivity, specialist consult notes). Requests without documentation consistent with the referenced criteria may be denied.

Follow the exact documentation checklist in the linked PDF/coverage page when present.
Examples of required supporting documentation include culture and sensitivity reports for infectious agents, LDL levels and prior lipid therapy for LDL-lowering agents, and specialist consultation notes for complex therapies.

Step Therapy

Prior authorization and attestation for long-acting opioids

Long-acting opioids (including certain ER formulations and methadone, fentanyl patches, etc.) require a provider attestation that the patient’s opioid management follows standard opioid-prescribing guidelines. Documentation must show a recent adequate trial (minimum 30 days continuous) with a short-acting opioid or other required steps per the PA criteria.

Provider attestation must state opioid management per standard guidelines and reference prior short-acting opioid trial (minimum 30 days continuous use) where required.
Missing opioid management attestation or absence of required prior short-acting opioid trial may trigger denial.

Prior Authorization

Product-specific PA nuances and device/CGM rules

Some products require specific PA nuances (e.g., tramadol ER, CAYSTON, cystinosis treatments, dalfampridine ER, CGMs and insulin-device coverage). Carefully follow product-specific rules for attestation, specialist prescribing, age limits, quantity and duration limits, and renewal evidence.

Tramadol ER: requires provider attestation per opioid-prescribing guidelines, an age restriction (adults and children ≥12), and initial quantity limits — new users limited to a short initial supply unless PA granted.
CAYSTON (aztreonam inhalation): approval only for cystic fibrosis patients with documented Pseudomonas aeruginosa, prescribed/managed by CF center specialists; initial approvals 12 months with annual renewal requiring recent CF center visit and effectiveness documentation.
CGMs (Dexcom, FreeStyle Libre): device PA often requires evidence of insulin use within the prior 6 months.
CYSTADROPS/CYSTARAN: require specialist prescribing for cystinosis; initial approvals commonly 3 months with renewal requiring slit-lamp exam notes or other treatment-effect documentation.
DALFAMPRIDINE ER: neurology prescribing, walking ability attestation, initial 6-month approval then annual renewals for responders with documented ambulation improvement.

Denial Risk

Time-limited initial approvals and continuation requirements

Initial approvals for some specialty or high-cost agents are time-limited and continuations require evidence of clinical benefit. Providers must submit reauthorization documentation (effectiveness measures, clinic visit notes, labs) per the PA criteria to receive extended approvals.

Examples: initial limited approvals (e.g., one month for VIBERZI; 3–6 months for others) with continuation approvals contingent on documented positive response.
Clinical evidence required for reauthorization varies by product — e.g., LDL reduction attestation for LDL-lowering agents, reduction in PN requirements for Gattex, improvement in ambulation for dalfampridine, or annual CF center visit for inhaled CF therapies.

Documentation Required

Specialist prescribing and organism- or condition-specific documentation

Specialist prescribing and disease- or organism-specific documentation is required for select agents. Examples include inhaled antibiotics for cystic fibrosis (Pseudomonas documentation and CF center prescribing), infectious disease consultation for Nuzyra, and neurologist prescribing for dalfampridine ER.

Nuzyra: reserved for cases meeting FDA indications, prescribing by or in consultation with Infectious Disease providers, and culture/sensitivity results are required.
Provide organism-specific lab reports (e.g., sputum culture showing Pseudomonas) when requested by the PA criteria.
Specialist attestation/prescription may be mandatory — include specialty clinic notes and recent visit documentation.

Denial Risk

Not medically necessary designations and allergy exceptions

Certain products are designated not medically necessary (NMN) when evidence does not show superiority to less costly alternatives (example: deflazacort/Emflaza and some related products). For these, coverage is not provided except when a documented allergy to the equivalent generic exists and other criteria permit.

Deflazacort (Emflaza) is considered not medically necessary due to insufficient evidence of superiority — brand may be reserved only for documented allergy to the generic.
If requesting an NMN product under an allergy exception, include clear allergy documentation in the medical record.

Documentation Required

Required supporting documentation and renewal evidence

Documentation expectations vary by product but commonly include: detailed prior-treatment history, dates and durations of trials, lab values (e.g., LDL, LFTs), weight/dose verification, culture/sensitivity, specialist consultation notes, evidence of functional improvement, and renewal visit notes. Submitting the specific items listed in linked PA PDFs speeds review and reduces denial risk.

Dose verification and relevant labs (e.g., weight and LFTs for Cholbam) where required.
Renewal documentation: e.g., annual CF center visit and effectiveness for inhaled CF agents; documentation of LDL reduction for lipid agents.
Supportive documentation per linked criteria — follow the PA PDF checklists and attach charts or clinic notes as specified.
Clinical documentation for specialty agents (e.g., Gattex: PN dependence and reduction in PN volumes) must be included for initial and renewal reviews.

Denial Risk

Denial risks and common triggers

Common denial triggers include failure to meet step-therapy or PA prerequisites (insufficient prior trial history, missing attestations, absent specialist documentation, age or quantity edits, or lack of required lab/clinical evidence). Denials may occur when requests lack the specific documentation referenced in the linked PA criteria.

Examples: missing opioid attestation for long-acting opioids; failure to document two preferred-product failures when required; lack of culture results or specialist consult for infectious disease agents.
If criteria are not met or documentation is insufficient, requests may be denied — include detailed chart evidence and referenced external PA forms to reduce risk.

Initial Therapy / Prior Authorization — Entry Conditions

Initial therapy PA/ST rules (general)

Initial coverage reserved when preferred therapies have failed or when contraindications exist.

Initial authorization: Prior trials are required: commonly failure of one or two preferred products unless there is documented contraindication or allergy; some drugs require additional documentation (e.g., literature support or specialist documentation).per product entry

See product‑specific linked PA documents when provided.

Initial therapy rules (general)

Initial coverage commonly requires prior trials or exceptions

Initial approval general: Reserved for FDA‑approved indications when patient has inadequate response to preferred alternatives, has medical contraindication, or has documented allergic reaction to equivalent generics; some products require specialist prescribing or product‑specific documentation/links.

Initial therapy durations

Product-specific initial approval duration when specified

CYSTADROPS/CYSTARAN initial: Initial approvals provided for three months.3 months

Renewals require documentation of clinical treatment effect (slit lamp exam) for up to one year.

DALFAMPRIDINE ER initial: Initial approval provided for six months.6 months

Continuation requires documented improvement in ambulation for one‑year approvals thereafter.

EMSAM initial therapy

Drug-specific initial therapy rules in excerpt

EMSAM initial/step: Require prior trials: at least three SSRIs AND at least one SSNRI AND at least one other antidepressant unless previously stable on EMSAM.

See PA entry for exact classes and counts.

Gattex initial therapy

Gattex-specific initial approval conditions

Gattex initial approval: Adult patients with short bowel syndrome dependent on chronic parenteral nutrition (>=4L daily) for at least one year AND dependent >=3 days/week; initial approvals for 3 months; reauthorization up to 1 year contingent on documented reduction in parenteral nutrition volume; doses up to 5 mg/day approved.PN >=4L daily; >=1 year; >=3 days/week

Dosing above 5 mg/day reviewed case‑by‑case.

Initial therapy rules (examples)

Common initial-therapy requirements seen in entries:

Insulin initial rules: Insulin products are reserved for FDA‑approved indications and typically require inadequate response or contraindication to preferred alternatives before coverage of non‑preferred insulin products.

Applies across multiple insulin entries.

Preferred-first requirement

Initial therapy/default coverage expectations for several products:

Fail preferred products first: Products are commonly reserved for patients with an inadequate response to two preferred alternatives or documented contraindications; some products require failing only one preferred alternative or have allergic exceptions.2 preferred products (commonly)

Deviations specified per product via linked PA pages.

Initial therapy (step requirements)

Typical initial-therapy requirements in this excerpt

Two preferred alternatives failed: Many branded or non‑preferred drugs are reserved for patients with inadequate response to two preferred alternatives (or medical contraindication).2 failed products

Examples include minocycline ER and others.

Three preferred NSAIDs failed: Certain naproxen CR/ER formulations require failure of three preferred NSAIDs before coverage.3 failed NSAIDs

Product‑specific requirement in NSAID entries.

Initial therapy / step therapy rules (general)

Typical initial therapy requirements referenced for many products in this excerpt:

Initial step therapy: Prior trial and inadequate response to two preferred alternatives (or three for select products) OR documented allergic reaction to preferred/generic agents; some products are reserved for FDA‑approved indications only.as stated per product

Product‑specific PA documents are linked for details.

Initial therapy requirements

Initial coverage conditions cited across products:

FDA‑approved indication + failures: Initial coverage commonly requires FDA‑approved indication plus inadequate response to two preferred alternatives or medical contraindication to their use.failure of 2 preferred alternatives

Applies across many listed products.

Initial therapy requirements (examples)

Common initial therapy rules in this segment

Fail preferred alternatives first: Many products require inadequate response to one or more preferred alternatives or dosage forms before approval.

Typical step logic.

Allergy to generic: Several products require a documented allergic reaction to the equivalent generic to qualify for brand coverage.

Allergy exception phrasing in product lines.

Initial therapy patterns

Common initial therapy rules in excerpt

Initial coverage patterns: Many products require prior trials of preferred alternatives (often two) and are reserved for patients with inadequate response or contraindication; some are reserved only when there is a documented allergic reaction to the generic.typically two preferred products

Exact requirements are product‑specific and linked.

Initial step requirements (examples)

Step/initial use requirements for listed products (examples)

Altabax initial coverage: Patient used generic mupirocin ointment within the previous 3 months.3 months

If not used within timeframe, prior authorization may be required.

Carbidopa‑levodopa ER initial coverage: Patient used carbidopa/levodopa ER capsule or generic carbidopa/levodopa within the previous 12 months.12 months

If not used within timeframe, prior authorization may be required.

Dexcom/FreeStyle Libre initial coverage: Patient has been using insulin in the previous 6 months.6 months

Step Therapy Rules and Tables

Step therapy requirement	Details / documentation required
Trial and inadequate response to one or two preferred alternatives
Coverage reserved when patient has tried and had an inadequate response to one or two preferred formulary alternatives before non-preferred product approval; medical record documentation of inadequate response required per product entry
Or documented medical contraindication or allergy to preferred alternatives

Step therapy requirement	Details / documentation required
Document prior trials of preferred alternatives or medical contraindication/allergy
Provider must supply chart documentation of prior trials/failures or a documented medical contraindication or allergic reaction to preferred products; some entries reference external PA documents for full criteria
Provider attestation required for certain agents (long-acting opioids, some buprenorphine/urgent opioid products)

Step therapy requirement	Details / documentation required
Document prior trials of preferred products
Many products are reserved for patients who have tried and failed preferred products (often two); provider must document trials or show medical contraindication/allergy
Some products specify trial of a preferred dosage form rather than a different molecule (document per product entry)

Step therapy requirement	Details / documentation required
Document prior OTC trial
For certain topical or antihistamine products, step criteria require trial of specified over‑the‑counter non‑sedating antihistamines (e.g., cetirizine, fexofenadine, loratadine) alone or with pseudoephedrine prior to coverage

Step therapy requirement	Details / documentation required
Most non‑preferred products require documented inadequate response to preferred products
Coverage is commonly reserved unless the patient has an inadequate response to specified preferred alternatives (commonly two) or has a documented allergic reaction or medical contraindication to the preferred agents; documentation in the medical record is required
Some entries require failure of three preferred agents for specific product classes (e.g., certain NSAIDs) — see product line for exceptions

Step therapy / attestation	Details / documentation required
Provider attestation for opioid prescribing guidelines
Long‑acting opioids and certain ER opioid products require provider attestation that opioid therapy is being managed per standard opioid prescribing guidelines
Documentation must include evidence of a recent adequate trial (minimum 30 days continuous use) of a short‑acting opioid and attestation of monitoring per guidelines

Step therapy requirement	Details / documentation required
Trial and failure of preferred alternatives; some products reference external PA documents
Many entries require trial and failure of one or two preferred alternatives before approval; several product lines link to detailed prior authorization PDFs or coverage pages that define full criteria
Providers must submit supporting documentation consistent with linked PA criteria when an external document is referenced

Step therapy requirement	Details / documentation required
Trials of preferred alternatives and/or documentation of contraindication or allergy
Coverage generally requires documented failure of preferred alternatives (often two) or documentation of medical contraindication/allergy; for long‑acting opioids provider attestation is required
Long‑acting opioid approvals additionally require documentation of an adequate recent trial (minimum 30 days continuous) of a short‑acting opioid

Step therapy requirement	Details / documentation required
Trials and failures of preferred agents or documented contraindication/allergy
Many products are reserved until the patient has tried and failed one or two preferred agents; documentation of trials/failures or a documented allergic reaction to the equivalent generic substitutes is required
Some products require specialist prescribing or additional clinical documentation per product entry

Step therapy requirement	Details / documentation required
Prior trials of preferred alternatives required before non‑preferred product coverage
Typical language: reserved for FDA‑approved indications and requires inadequate response to two preferred alternatives or medical contraindication to their use; providers should follow any linked PA criteria for product‑specific exceptions
When external PA links are provided, providers must supply documentation per that referenced criteria

Step therapy / attestation	Details / documentation required
Provider attestation confirming guideline‑based opioid management
Long‑acting opioid products require a provider attestation that therapy is managed per standard opioid prescribing guidelines, including confirmation of a prior adequate short‑acting opioid trial (minimum 30 days continuous use)

Step therapy requirement	Details / documentation required
Trial and failure (or contraindication/allergy) of preferred formulary alternatives before approval
Coverage commonly requires documented failure of two preferred formulary alternatives; some products specify different trial counts (e.g., three for certain NSAIDs) or accept documented contraindication/allergy instead
Documentation in the medical record supporting trials, reasons for discontinuation, or allergy documentation must be provided

Step therapy requirement	Details / documentation required
Trials of preferred therapies required prior to coverage; some reference specific PA documents
Many products require prior trials (commonly two) of preferred therapies before non‑preferred coverage; individual product entries may point to specific HealthPartners PA PDFs for full criteria
Providers should reference and submit materials consistent with the linked PA documents when specified

Step therapy requirement	Details / documentation required
Trial and failure of preferred alternatives prior to approval unless exception documented
Non‑preferred product coverage typically requires documented failure of one or two preferred alternatives; exceptions include documented allergy or medical contraindication to preferred agents
When exceptions are claimed (e.g., allergy), medical record evidence must be submitted to support the exception

Step therapy requirement	Details / documentation required
Trial and inadequate response to specified number of preferred alternatives or documented allergy/contraindication
Coverage requires documented inadequate response to the number of preferred alternatives specified in the product entry (commonly one or two) or documentation of allergy/contraindication; some products also require specialist prescribing or additional supporting documentation
Failure to document required prior trials or exceptions may result in denial of coverage

Step therapy requirement	Details / documentation required
Try and fail preferred alternatives before approval
Multiple products are explicitly reserved for patients who have tried and failed one or more preferred products or dosage forms before coverage of the non‑preferred product; clinical rationale and documentation of trials should be provided

Step therapy / attestation	Details / documentation required
Provider attestation of opioid management and prior trial documentation
For tramadol ER, long‑acting opioids and similar agents, coverage requires a provider attestation that opioid prescribing guidelines are followed and documentation of an adequate prior trial (minimum 30 days continuous) of an immediate‑release short‑acting opioid
Additional age‑ or quantity‑limits may apply per product (see product line entries)

Step therapy requirement	Details / documentation required
Step therapy enforced for many products with product‑specific exceptions via linked PA documents
Numerous product lines enforce step therapy but provide product‑specific exceptions or detailed PA criteria via HealthPartners links; providers must follow and submit documentation per those external criteria where provided
Documentation may include prior trial history, specialist consult notes, laboratory results, or literature evidence as specified by the linked criteria

Step therapy requirement	Details / documentation required
Use of specified generic or preferred alternatives within defined prior time windows before coverage
Some products require documented use of specific generics or preferred alternatives within a defined prior timeframe (examples: Altabax — generic mupirocin within prior 3 months; carbidopa‑levodopa ER — prior 12 months; Eucrisa/Opzelura — prior tacrolimus/pimecrolimus within prior 12 months or 365 days); providers must document timing of prior use
When device or CGM coverage is requested (e.g., Dexcom, FreeStyle Libre), documentation of insulin use within the prior 6 months is required per the referenced PA documents

Note

Key Definitions and Terms

Step Therapy (ST) — definition

DefinitionStep Therapy (ST) is a coverage approach requiring patients to try one or more other medicines first before coverage of a non‑preferred drug

PurposeEnsures preferred, typically lower‑cost therapies are tried prior to non‑preferred agents

Typical requirementOften requires trial and inadequate response to one or two preferred alternatives, unless contraindicated or allergic

Prior Authorization (PA) — definition

DefinitionPrior Authorization (PA) is a requirement that certain medicines meet HealthPartners' PA criteria for coverage under pharmacy benefits

ImplicationMedication will not receive lowest‑tier coverage without approved PA documentation

Where specifiedPA criteria are provided inline per product or via linked HealthPartners PA PDFs

Step Therapy (ST) — alternate excerpt

Definition (alt)Step Therapy reserves non‑preferred drugs for patients who have failed or are contraindicated to preferred alternatives; number of required failures specified per product

DocumentationMay require documentation in the medical literature of benefit over preferred alternatives for some agents

ExceptionsDocumented allergy or medical contraindication to preferred agents may qualify a patient without required failures

Step Therapy (ST) — alternate excerpt

Definition (alt)Step Therapy: use of preferred medications is required before coverage of non‑preferred agents; applied as trials of preferred products or documented contraindications/allergies

EnforcementProduct lines often state 'Reserved for' language indicating required prior trials or exceptions

Provider actionSubmit documentation of prior trials or contraindications per PA requirements

Reserved for patients with a documented allergic reaction to the equivalent generic

Definition'Reserved for patients with a documented allergic reaction to the equivalent generic' — coverage allowed when member has allergy to the generic equivalent

UseCommon exception used across many brand entries to permit non‑preferred coverage

DocumentationMedical record must document allergic reaction to the generic/formulary alternative

Inadequate response to preferred alternatives — definition

Definition'Inadequate response to preferred alternatives' — clinical evidence that member had an inadequate therapeutic response or intolerable side effects to preferred products

Typical requirementOften requires failure of one or two preferred alternatives before non‑preferred coverage

DocumentationProvider chart notes or prior medication history should demonstrate inadequate response

Reserved for patients with an inadequate response to preferred alternatives

Definition'Reserved for patients with an inadequate response to preferred alternatives' — coverage only when member has inadequate response to specified preferred options or medical contraindication

Common thresholdFrequently requires failure of two preferred alternatives; exact number varies by product

Provider actionDocument prior trials, including timing and outcomes, per product PA criteria

Provider attestation (opioids) — definition note

DefinitionProvider attestation (opioids) = clinician statement that opioid therapy is managed per standard opioid prescribing guidelines

ApplicabilityRequired for many long‑acting opioid prior authorizations

IncludesConfirmation of prior adequate short‑acting opioid trial and adherence to monitoring and risk‑reduction practices

Reserved for patients with documented allergic reaction to equivalent generic/brand

Definition'Reserved for patients with a documented allergic reaction to the equivalent generic/brand' — coverage limited to members with documented allergy to cheaper equivalent

ImplicationPA required to confirm allergy and allow coverage of non‑preferred product

Common useAppears across many product entries as an exception to step therapy

Failure of preferred alternatives — definition note

Definition'Failure of preferred alternatives' = patient has had inadequate response to the number of preferred products specified (commonly two)

EvidenceChart notes or prior pharmacy records should show trials and outcomes of preferred agents

PA consequenceLack of documented failures may result in denial of request

Reserved for FDA‑approved indications — definition note

Definition'Reserved for FDA‑approved indications' — coverage limited to uses approved by the FDA unless product‑specific PA criteria allow otherwise

DocumentationProviders may need to confirm indication and meet any linked PA criteria for approval

Typical pairingOften paired with step therapy requirements or specialist prescribing mandates

Reserved for patients with a documented allergic reaction to the equivalent generic

DefinitionBrand coverage reserved only when there is a documented allergic reaction to the equivalent generic — used to permit non‑preferred brand use

Common productsApplied to multiple brands and specialty formulations across the drug list

Required evidenceMedical record documentation of allergic reaction required for PA approval

Step Therapy (ST) — alternate excerpt

Definition (alt)Step Therapy: initial approvals commonly time‑limited (e.g., 6 months) and require prior trials of preferred alternatives; renewals for responders may be annual

ImplicationSome products explicitly state initial approval duration and renewal criteria

Provider actionDocument response during initial period to support continuation

Step Therapy (ST) — alternate excerpt

Definition (alt)ST requires preferred therapies be tried first; non‑preferred agents are reserved for patients with inadequate response, contraindications, or documented allergies

Common languageEntries often use 'Reserved for' phrasing to indicate required prior steps or exceptions

Where to find detailsProduct‑specific PA links provide exact step counts and exception criteria

Reserved — usage note

Usage note'Reserved' indicates coverage only under specified conditions (e.g., allergy, inadequate response, FDA indication, specialist prescribing)

ScopeUsed widely across product entries to limit coverage to specified circumstances

Provider implicationMust submit supporting documentation to demonstrate the reserved condition is met

Reserved for FDA‑approved indications — definition note

Definition'Reserved for FDA‑approved indications' — coverage limited to FDA‑approved uses and may require prior failures of preferred alternatives

DocumentationProviders should reference product‑specific PA documents when coverage outside listed indications is sought

Common pairingOften paired with step/failure language in entries

Documented allergic reaction to equivalent generic — definition note

Definition'Documented allergic reaction to equivalent generic' — explicit medical record evidence that precludes use of the generic formulation

EffectPermits coverage of brand/non‑preferred formulation when documented

Required evidenceChart note describing allergic reaction and provider confirmation

Documented allergic reaction to equivalent generic — alternate excerpt

Definition (alt)Documented allergic reaction to equivalent generic — coverage exception when medical record documents allergy to generic alternative

Use casesCommon across many branded and specialty product entries

PA requirementPA will require documentation confirming the allergic reaction

Failed preferred alternative — definition note

Definition'Failed preferred alternative' = clinical evidence member had inadequate response or intolerable side effects to one or more preferred agents

Typical thresholdOften requires failure of two preferred products unless product specifies otherwise

DocumentationMedical record or pharmacy history should document failure(s)

Reserved for patients with documented allergic reaction to equivalent generic (alternate excerpt)

Definition'Reserved for patients with a documented allergic reaction to the equivalent generic' — repeated exception language used across entries

Provider actionInclude allergy documentation with PA request to support exception

ConsequenceNo coverage without documented allergic reaction unless other exceptions apply

Reserved for cystic fibrosis patients with Pseudomonas aeruginosa — definition note

Definition'Reserved for (1) use in cystic fibrosis patients known to have Pseudomonas aeruginosa' — indicates agent is limited to CF patients with documented organism

PrescribingMust be prescribed and managed by specialists from a cystic fibrosis treatment center

Quantity/renewalQuantity limits and annual renewal documentation required (see product line for specifics)

Reserved for patients with an inadequate response to two preferred products

Definition'Reserved for patients with an inadequate response to two preferred products' — coverage allowed after documented failure of two preferred alternatives

CommonalityFrequent step therapy threshold across many products in the list

DocumentationProvider must document trials and inadequate responses to the two preferred agents

Reserved for patients with documented allergic reaction to equivalent generic (alternate excerpt)

Definition'Reserved for patients with a documented allergic reaction to the equivalent generic' — repeated across product entries as an exception to step therapy

Required evidenceChart documentation of allergic reaction required for PA approval

Provider implicationLack of documentation may result in denial

OpenPayer

Commercial 2026 Formulary Prior Authorization and Step Therapy Coverage Criteria

Coverage Criteria and Product Notes

Provider Requirements, Documentation, and Denial Risks

Initial Therapy / Prior Authorization — Entry Conditions

Continuation and Renewal Requirements

Step Therapy Rules and Tables

Key Clinical Thresholds and Coding Values

Quantity Limits and Site-of-Care Notes

Site-of-Care and Specialist Prescribing Requirements

Key Definitions and Terms

Background and Scope

Biosimilar and Related Product Notes