Prior Authorization Required — Prior Authorization, Step Therapy, Documentation & Denial Risks

Many medicines listed on the drug table require prior authorization (PA) before they will be covered under HealthPartners pharmacy benefits. This includes high-tier antivirals (for example, hepatitis C regimens such as HARVONI, MAVYRET, EPCLUSA/SOFOSBUVIR-VELPATASVIR and similar agents), numerous specialty and oncology therapies, many coagulation and infusion products, and selected extended‑release or other specified formulations. Failure to obtain required PA, to meet specialty/oncology program designations (S, ONC), or to comply with quantity limits (QL) and step therapy (ST) rules may result in denial of coverage.

• Prior authorization (PA) is required for many listed products — providers must obtain PA before dispensing to avoid claim denial.
• High‑tier antivirals and hepatitis C therapies (e.g., HARVONI, SOFOSBUVIR‑VELPATASVIR, SOVALDI, EPCLUSA, MAVYRET, GENVOYA/related regimens) are frequently designated PA and often S (specialty).
• Oncology and antineoplastic agents commonly carry combined requirements: PA; ONC (oncology benefit); S (specialty); TD (trial drug) and QL (quantity limits).
• Coagulation factor concentrates and many infusion therapies require PA and are often dispensed through specialty channels (PA; S) with specific QL or per‑period caps.
• Certain formulations — extended‑release opioids, extended‑release neurologic agents, and specific specialty formulations (e.g., sodium oxybate, XYREM/XYWAV) — are subject to PA and QL.
• Quantity limits (QL) are enforced (examples: PAXLOVID, oseltamivir dose‑packs, many antivirals and specialty inhalation/nebulized products); requests above QL will be reviewed for medical necessity and may be denied or require clinical justification.
• Step therapy (ST) applies where noted (e.g., TRINTELLIX, some zolpidem extended‑release products); some entries show 'S' indicating step/specialty program requirements — however, many entries do not contain explicit step sequences.
• Specialty drug documentation: products marked 'S' often require specialty pharmacy dispensing, additional clinical documentation, and PA submission that demonstrates medical necessity and prior steps when applicable.
• Documentation expectations: PA requests and overrides for QL or ST must include supporting clinical information — diagnosis, prior therapies tried/failed, evidence of response or need for quantities beyond standard QL, and rationale for specialty/oncology exceptions.
• Denial triggers: absence of an approved PA, exceeding QL without justification, failure to meet ONC/S/TD program criteria, or not satisfying step therapy requirements may result in claim denial or non‑coverage.
• Operational note: providers should follow HealthPartners' PA submission process and include all requested supporting documentation to expedite decisions; failure to include required documentation may delay or prevent approval.