Prior Authorization Required — high-level action summary for PA

Prior authorization (PA) is required for many formulary products shown with a PA flag. Prescribers or pharmacies must obtain approval before dispensing to avoid claim denial. When a product line lists PA (or combined flags such as PA; S; ONC), submit a PA request with clinical justification before the fill.

• PA = Prior Authorization required; claims without approved PA may be denied
• Many specialty, oncology, high‑cost and intravenous products list PA; S (Specialty) and ONC (Oncology) together
• Opioid Program (OP) and Trial Drug (TD/TD) entries may also require PA

Prior authorization and restrictions — PA, S, QL explanation and impact

When a formulary line includes a PA flag the provider must: obtain prior authorization before the first fill, include supporting documentation (diagnosis, prior therapies tried, dosing rationale), and adhere to any listed Quantity Limits (QL) or Step Therapy (ST) requirements. Missing PA, missing required documentation, or exceeding QL may trigger utilization management review and possible denial.

• Provide clinical notes, prior medication history and rationale when submitting PA
• If a product shows ST or TD, document that step requirements were met or request an exception
• QL values (e.g., QL (4 per 30 days)) indicate enforced maximums and must be justified for overrides

Prior Authorization required — many listed drugs require PA

Many listed drugs across therapeutic classes require PA — examples include specialty biologics, oncology agents, high‑cost antivirals, and select neurologic or seizure medications. Specialty (S) designation often accompanies PA and implies additional paperwork and routing to specialty/pharmacy channels.

• Oncology products frequently display PA; ONC; S; QL (e.g., multiple oral antineoplastics)
• Neurology/epilepsy agents (KEPPRA, VIMPAT, XCOPRI) often show PA and QL
• Hepatitis C/hepatitis antivirals and other high‑cost antivirals commonly show PA; S

Prior authorization required when PA flag present — PA with ONC/S/TD context

When a specialty, IV or clotting‑factor product lists PA (often with S), the provider must submit specialty‑level documentation (treatment plan, dosing schedule, prior authorizations for past courses) and coordinate with the plan’s specialty pharmacy if required.

• Injectable clotting‑factor and IV biologics are frequently PA; S — e.g., ALPHANATE, ALPROLIX, JIVI
• Specialty products may require quantities expressed per dosing period (units per 28/30 days) and reconciliation documentation

Prior Authorization required — examples of products requiring PA (neurology/epilepsy listing)

PA is enforced for many named products in the table. Examples: certain opioid and analgesic controlled‑release products, selected antiepileptics, migraine biologics, and numerous specialty oncology agents. Check the formulary line for the PA flag and any co‑flags (ST, QL, OP, ONC) before prescribing or dispensing.

• Opioid product examples: OXYCONTIN, OXYMORPHONE entries list PA; OP; QL
• Antiepileptic examples: KEPPRA, VIMPAT, XCOPRI show PA (often with QL)
• Migraine biologics: AIMOVIG, AJOVY include PA; QL

PA plus quantity limits — examples where both PA and QL apply

PA may be combined with Quantity Limits (QL); when both apply, supporting documentation is required to exceed the stated QL. Requests above QL will be reviewed for medical necessity and may be denied without sufficient justification.

• QL examples: LYRICA CR and immediate‑release LYRICA list PA; QL (per day) limits
• Claims exceeding QL require documentation of medical necessity and prior use within limit
• Tramadol and other opioid entries frequently show PA; OP; QL — adhere to opioid program limits

Prior Authorization required for specified products — specialty/high‑cost examples

Specialty and oncology flags (S, ONC, TD) signal that additional supporting documentation and prior authorization steps are required; these products are routed through specialty review and may have per‑course or per‑period QL (for example, QL expressed as units per 28 or 30 days).

• ONC and TD typically accompany PA for oral antineoplastics and targeted therapies
• Examples show QL expressed as a count per day or per 28/30 days (e.g., QL (21 per 28 days))
• Specialty routing may change where the drug is dispensed (specialty pharmacy required)

Specialty IV products require PA — injectable clotting‑factor/IV examples

Some high‑cost IV and specialty products (including clotting factors and enzyme/replacement therapies) explicitly require PA and specialty handling. Expect prior authorization review to include dosing logs, prior authorization history, and documentation of diagnosis and therapeutic necessity.

• IV clotting‑factor products (e.g., ALPHANATE, ALPROLIX, ALTUVIIIO) list PA; S
• Remodulin and other parenteral specialty agents show PA; S routing
• Submit weight/dosing and units per period documentation for IV products when requested

Rivaroxaban PA/QL — anticoagulant examples with PA and QL

Rivaroxaban entries show mixed requirements: certain formulations list PA with a QL and others list QL only. Verify the specific NDC/formulation; if PA; QL is present, obtain PA and ensure quantity does not exceed the stated limit.

• Rivaroxaban oral suspension: Requirements = PA; QL (20 per 1 day)
• Rivaroxaban 2.5 mg tablets: Requirements = QL (2 per 1 day)

Opioid Program denial risk — specific opioid program enforcement if PA not obtained

For opioid‑program flagged products (OP), initial prescriptions may be limited to smaller supply and longer therapy often requires PA. Failure to obtain required authorization for OP entries or to adhere to QL limits increases the risk of coverage denial.

• Opioid program entries (OP) denote shorter initial supply and enforced QL
• Longer opioid therapy requires prior authorization — obtain PA early to avoid interruption
• Claims for opioid products without required PA or exceeding QL are at higher risk for denial

UM triggers for denial — missing PA/S/ONC may cause denial

Utilization management (UM) triggers for denial include: absence of required PA, missing or insufficient supporting documentation, failure to meet ST/TD requirements, and exceeding QL without medical‑necessity justification. Providers should confirm requirements on the formulary line before prescribing.

• PA missing on a PA‑designated product may result in denial of coverage
• ST/TD requirements must be documented or an exception requested
• Exceeding a QL without justification can trigger UM denial

Quantity limit enforcement — QL exceedance handling and documentation

Quantity limits are enforced where listed (QL). Requests above the QL will be clinically reviewed; to avoid denial, include documentation showing prior use at the requested dose, clinical necessity, and rationale for exceeding the limit.

• Examples: QL (4 per 30 days), QL (21 per 28 days), QL (1 per 1 day) — adhere to the per‑period unit definitions
• Pharmacies submitting overrides should attach medical justification and prior therapy records
• Some QL values apply per day, per 28 days or per 30 days — confirm the period before submitting

Step Therapy Requirement — explanation of ST flag and its effect

Step therapy (ST) applies where shown; the prescriber must document that required first‑line therapies were tried and failed or request an exception. For certain biologics and specialty agents, ST is required and is shown alongside QL where applicable.

• ST = Step Therapy; REPATHA examples show ST with QL limits
• If ST is indicated (ST or ST; QL), document prior agents tried and outcome
• When a product lists ST but no specifics are on the line, consult the plan or prior authorization criteria for the step‑therapy algorithm

Documentation for quantities over limit — supporting docs required for exceptions

Documentation must accompany PA and any request to exceed QL or bypass ST. For specialty/oncology products include treatment plan, prior regimen history, dosing schedule, and any relevant lab or imaging reports. Insufficient documentation increases the chance of denial.

• Supporting docs: diagnosis, prior therapies, response/failure notes, dosing and duration
• Specialty/ONC products: include oncology treatment plan and cycle counts (units per 28/30 days)
• Quantities over a limit require explicit supporting clinical rationale

Required documentation flags — mapping of PA/ST/S/QL to provider actions

The formulary legend and table headers explain symbols and where to find specific PA/ST/QL meanings. Always consult the table heading and the explanation section (List of Abbreviations) for symbol definitions before acting on a formulary line.

• Refer to the List of Abbreviations for PA, ST, QL, S, ONC, OP, TD
• Table entries include both the drug line and a Requirements / Limits field — review both
• When in doubt, contact HealthPartners prior authorization services or check myHealthPartners for plan‑specific rules

Fill specialty medicines at specialty pharmacy per formulary

Specialty medicines must be dispensed via a specialty pharmacy and may be covered under a different benefit than retail‑dispensed medicines; check member benefits for specialty coverage rules.

Coordinate PA and site‑of‑care for infusion/specialty products

Infusion or injectable specialty products flagged 'S' may require specialty channel routing or infusion‑center handling; coordinate site‑of‑care and PA accordingly.

Verify outpatient (OP) site‑of‑care requirements

OP/OP flags indicate outpatient dispensing or site‑of‑service; when OP is shown, verify benefit and site‑of‑care requirements before arranging treatment.

Confirm OP/site indicators for oral formulations

Some oral formulations include OP/site indicators — providers should confirm appropriate dispensing setting and any PA/site requirements shown on the line.

Arrange PA and infusion‑center coordination for injectable specialty drugs

Injectable specialty products listed with PA and S (e.g., REMODULIN, FLOLAN) may require infusion‑center coordination and prior authorization; providers must secure PA and arrange specialty distribution.

Route 'S'‑flagged products through specialty distribution

An 'S' flag on a formulary line indicates specialty channel or specialty distribution is required; providers must route dispensing to specialty pharmacy when 'S' is present.