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Non-Preferred Drug Prior Authorization List (partial)

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List of medications designated as nonpreferred and subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization criteria; indicates reserved uses or required clinical criteria links for specific products. Affects providers prescribing these medications for HealthPartners members.

Policy Summary

PayerHealthPartners

PolicyNon-Preferred Drug Prior Authorization List (partial)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization per Minnesota DHS Non-Preferred Drug Prior Authorization Criteria and submit required clinical documentation or referenced HealthPartners criteria PDFs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+medications listed

20+drug entries

Minnesota-specificMinnesota-specific PA

multiplelinks to criteria

reservedreserved uses noted

Coverage Criteria — Nonpreferred Drugs

Reserved-use coverage criteria (partial)

Covered only when reserved-use conditions are met (examples recorded in this extract):

examples: Reserved for patients with an inadequate response to two or more preferred products OR with medical contraindications to preferred products; documentation in the medical literature of clinical benefits over preferred alternatives may be requiredfailure of >=2 preferred products

applies to multiple listed medications (see linked criteria)

pediatric restrictions: For children 6 years of age and younger, some medications are reserved for prescribing by Behavioral Health providers or for patients previously stable on the medicationage <=6

example provided for multiple antipsychotic and other pediatric entries

Policy Summary

PayerHealthPartners

PolicyNon-Preferred Drug Prior Authorization List (partial)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization per Minnesota DHS Non-Preferred Drug Prior Authorization Criteria and submit required clinical documentation or referenced HealthPartners criteria PDFs.

SourceLink

On This Page

allergic to generic:

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

applies to several topical, oral, and other products

Product-level reserved-use and PA criteria (excerpt)

Products are covered only when they meet the MHCP Non-Preferred Drug Prior Authorization criteria or the product-specific reserved-use conditions below

examples: Examples of product-specific reserved-use conditions include: reserved for patients with a documented allergic reaction to the equivalent generic; reserved for patients with an inadequate response to one or more preferred products or dosage forms; reserved for patients with contraindications to preferred alternatives; reserved for FDA-approved indications; reserved for pediatric prescribing by Behavioral Health providers or for previously stable patients. Some products require documentation in the medical literature of benefit over preferred alternatives.

See individual product lines for linked MHCP criteria documents where provided.

Non-Preferred Drug Coverage Conditions (B–C)

Covered only when specified criteria are met (per-entry rules vary).

per-drug criteria: Each listed non-preferred medication is subject to its specified required clinical criteria: common conditions include reserved for FDA-approved indications; reserved for documented allergic reaction to equivalent generic; reserved for inadequate response to preferred dosage form; or subject to MHCP Non-Preferred Drug Prior Authorization Criteria. Specific drugs may reference external HealthPartners coverage documents.

See individual drug entry for exact requirement; this segment lists drugs B–C.

Opioid Products — Attestation & Trial Requirement

Additional opioid-specific requirement when applicable:

opioid attestation and trial: For long-acting opioid products and some opioid-related medications, provider attestation is required that therapy is managed per standard opioid prescribing guidelines AND patient has had an inadequate response to a recent adequate trial (minimum 30 days continuous use) of a short-acting opioid where specified.minimum 30 days

Referenced repeatedly across several listed opioid products.

General coverage for non-preferred medications

Covered only when prior authorization per Minnesota DHS Non-Preferred Drug PA criteria is approved or specific reserved conditions are met.

General requirement: Medication is designated non-preferred; prior authorization per Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria or referenced HealthPartners clinical criteria must be met.

Some products have product-specific links or reserved-use clauses (e.g., allergic reaction to generic, specialist prescribing, or inadequate response to preferred products).

Product-specific additional conditions

Certain products have additional specific coverage conditions.

CAYSTON (aztreonam inhalation): Approved for cystic fibrosis patients known to have Pseudomonas aeruginosa, prescribed and managed by CF center specialists, quantity up to one 28-day package per month; initial approval 12 months; renewals annually with CF center visit documentation and effectiveness.initial & renewals = 12 months

See CAYSTON REQUIRED CLINICAL CRITERIA.

CHOLBAM: Reserved for prescribing by a specialist for patients with bile acid synthesis disorders due to single enzyme defects or adjunctive treatment in peroxisomal disorders, with dose and weight documentation required; authorizations provided for 6 months and reauthorization based on liver function improvement.authorizations = 6 months

See CHOLBAM REQUIRED CLINICAL CRITERIA.

General reservation and PA criteria patterns (per-drug specifics apply)

Covered when ALL of the following reservation conditions are met (per individual drug entry):

Specialist prescriber or indication: Some medications are reserved for prescribing by specific specialists (e.g., Behavioral Health providers for selected pediatric psychotropics; Neurologist for DALFAMPRIDINE ER; specialists for cystinosis drugs).

See individual drug entry for required prescriber specialty.

Documented allergy or contraindication to generic/preferred: Multiple entries state reservation for patients with a documented allergic reaction to the equivalent generic or documented medical contraindication to preferred products.documented allergy/contraindication

Common across many listed drugs.

Prior trial / inadequate response: Several products require prior inadequate response to one or more preferred products (often two) or to an adequate trial of a short-acting alternative before long-acting formulations are authorized.often >=2 preferred failures or specified short-acting trial

E.g., opioids, topical agents, oral diabetes medicines.

Special monitoring or documentation for renewals: Some specialty agents require documentation of clinical benefit for renewals (e.g., slit lamp exam notes for CYSTADROPS/CYSTARAN), with specific initial approval durations noted (e.g., 3 months initial then up to 1 year).

See individual product entries for details.

General PA approval logic (extract)

Coverage for each listed nonpreferred medication follows Minnesota DHS Non-Preferred Drug Prior Authorization Criteria and, where specified, the referenced HealthPartners clinical criteria documents. Common approval conditions in this extract include:

Typical approval conditions: - Reserved for FDA‑approved indications; OR - Reserved for patients with inadequate response to one or more preferred alternatives (often two); OR - Reserved for patients with documented allergic reaction or contraindication to equivalent generic/preferred product; OR - Requires documentation of clinical benefit over preferred products; OR - Specific drugs have unique limits (e.g., fidaxomicin approvals limited to 10 days).

Extracted common logic examples from multiple drug entries in chunks 90–109.

Coverage contingent on linked PA criteria

Covered when the specific HealthPartners or Minnesota DHS MHCP Nonpreferred Drug Prior Authorization criteria (linked per drug) are met.

General PA requirements: Member must meet the specific required clinical criteria linked for the individual drug (e.g., MHCP Nonpreferred Drug PA criteria or HealthPartners clinical criteria PDF).

Follow the document URL provided for each medication.

General Non-Preferred PA Coverage

These nonpreferred medications are covered only when meeting the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria or the specific HealthPartners required clinical criteria referenced for the drug.

General MHCP nonpreferred PA requirement: Medication is nonpreferred and requires prior authorization per Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria or specific HealthPartners required clinical criteria URL provided in the entry.

Applies to each listed product unless a different specific requirement is noted.

Drug-specific reserved conditions

Some entries specify more-limited coverage conditions.

Reserved for allergy or inadequate response: Certain brand or multi-source brand products are reserved for patients with a documented allergic reaction to the equivalent generic, or for patients with an inadequate response to preferred dosage forms.

Examples include multiple topical and oral agents noted in the listing.

Fentanyl formulations: Long-acting fentanyl patches require provider attestation of opioid prescribing guideline management and prior adequate trial (minimum 30 days continuous use) of a short-acting opioid; some fentanyl products reserved for breakthrough cancer pain in opioid‑tolerant patients after failure of preferred products.30 days

MN DHS Non‑Preferred Drug PA Criteria applies.

C. difficile reserved drugs: Agents for C. difficile (e.g., fidaxomicin) are reserved for patients with a diagnosis of C. difficile infection and inadequate response or contraindication to one or more courses of vancomycin; approvals limited where specified (e.g., fidaxomicin limited to 10 days).10 days (fidaxomicin)

See DIFICID/FIDAXOMICIN entries.

GATTEX — Initial and Reauthorization Criteria

GATTEX coverage criteria (excerpt)

GATTEX initial approval: Adult patients with short bowel syndrome significantly impaired in functional capacity due to chronic parenteral nutrition requirements (e.g., >=4L daily) who have been dependent on parenteral nutrition for at least one year AND at least three or more days per week.parenteral nutrition >=4L/day; >=1 year dependence; >=3 days/week

Initial approvals will be granted for three months.

GATTEX reauthorization: Reauthorizations provided for up to one year with a documented reduction in parenteral nutrition volume requirements.documented reduction in PN volume

Doses up to 5 mg daily approved; other doses reviewed case‑by‑case.

Hydromorphone ER — Management and Trial Requirements

Hydromorphone ER (MHCP note)

Opioid management attestation: Provider must attest therapy is being managed per standard opioid prescribing guidelines.

Required for long‑acting opioids.

Prior short-acting opioid trial: Patient must have had inadequate response to a recent adequate trial (minimum 30 days continuous) with a short‑acting opioid prior to long‑acting opioid approval.>=30 days continuous short‑acting opioid trial

Applies before MHCP non‑preferred long‑acting product approval.

General coverage conditions for listed non-preferred drugs

Coverage for listed non-preferred medications is subject to meeting ALL of the following as applicable:

Primary requirement: Drug is non-preferred and requires prior authorization per Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria or HealthPartners required clinical criteria PDFs linked in the document.

Links provided next to many entries

Reasons permitting coverage: Coverage may be approved when one of the following is documented: (1) documented allergic reaction to equivalent generic; (2) inadequate response to preferred products or preferred dosage forms; (3) reserved for FDA‑approved indication where specified; (4) for long‑acting opioids, provider attestation plus prior short‑acting opioid trial of at least 30 days.

Specific items list which condition applies (see per‑drug lines)

Special product-specific rules: Some products require additional documentation or are billed as medical claims (e.g., specified insulin pump billed through DME where PA not required if billed through DME vendor).

See product entries for exceptions.

General Non-Preferred Drug Coverage Criteria

Covered when ALL of the following are met (generalized from 'reserved' entries):

General reserved criteria: 1) Drug is prescribed for an FDA‑approved indication when specified; AND 2) Documentation shows inadequate response to preferred dosage form(s) or medical contraindication to preferred product, or documented allergic reaction to equivalent generic when that language is used; AND 3) If a specific HealthPartners prior authorization document URL is listed for the drug, the conditions in that linked document must be met.

Applies variably per drug; see individual drug‑linked criteria.

Lanreotide (Somatuline Depot) Coverage

Covered when ALL of the following are met:

Lanreotide initial and continuation: 1) Patient for whom surgery is not an option or surgery was not curative; AND 2) Patient has failed one somatostatin analogue; AND 3) Initial approval limited to six months; continuation approvals annually for demonstrated responders.initial approval = 6 months

From LANREOTIDE ACETATE REQUIRED CLINICAL CRITERIA.

Type 2 Diabetes Product Documentation

Covered when ALL of the following are met:

Type 2 diabetes products (e.g., JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JENTADUETO XR): 1) Reserved for diagnosis of an FDA‑approved indication; AND 2) Documentation to confirm diagnosis of type 2 diabetes supported by one of the following: ICD‑10 code, medical records/chart notes, A1C or other lab result.

From listed REQUIRED CLINICAL CRITERIA entries.

L-glutamine: specific medical necessity criteria

Examples of explicit reservation/coverage logic found in the excerpt include:

L-glutamine (for Sickle Cell Disease): 1) Diagnosis of Sickle Cell Disease; AND 2) Patient >= 5 years old; AND 3) Patient has experienced >=2 painful crises in prior 12 months despite continuous hydroxyurea (unless contraindicated); AND 4) Prescribed within FDA approved dose; AND 5) For MHCP nonpreferred products, meet Minnesota DHS Nonpreferred Drug PA criteria; initial and reauthorizations for 12 months; renewals annually when medication provides positive impact (reduced painful crises).initial & reauthorizations = 12 months

From L‑GLUTAMINE REQUIRED CLINICAL CRITERIA.

Lanreotide: coverage criteria

Lanreotide (Somatuline Depot): Reserved for patients for whom surgery is not an option or not curative, and who have failed one somatostatin analogue. Initial approvals are for six months; annual approvals thereafter for responders.initial = 6 months

From LANREOTIDE ACETATE REQUIRED CLINICAL CRITERIA.

General reservation rules across entries

Agents reserved for allergy to generic: Multiple listed medications are reserved for patients with a documented allergic reaction to the equivalent generic (examples noted across entries).

chunks 198,207,210

Agents reserved after inadequate response: Several medications are reserved for patients with an inadequate response to preferred dosage forms or two preferred alternatives, or with contraindications to preferred agents (examples: levofloxacin, levorphanol).

chunks 204,205,210

Coverage conditional patterns

Coverage for listed non-preferred medications is conditional and varies; common criteria patterns include:

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

appears for multiple agents across the list

Reserved for inadequate response to preferred products: Reserved for patients with an inadequate response to one or more preferred products or dosage forms, or with medical contraindications to preferred therapies.often two or more preferred products

language appears for multiple agents

Long-acting opioid specific requirements: Long-acting opioids require a provider attestation that therapy is managed per standard opioid prescribing guidelines and that patient had an inadequate response to a recent adequate trial (minimum 30 days continuous use) of a short‑acting opioid; MHCP Non‑Preferred Drug PA criteria also apply.30 days

applies to methadone, morphine ER, others.

Indication-specific reservation: Some drugs are reserved for specific FDA‑approved indications or conditions (e.g., MOVANTIK reserved for opioid‑induced constipation after inadequate response to laxatives).

see individual drug lines.

Reference to external required clinical criteria: Coverage requires meeting HealthPartners required clinical criteria documents (links provided) or MHCP Non‑Preferred Drug PA criteria.

multiple links cited.

Coverage conditional on drug-specific criteria

Non-preferred medications are covered only when the specific required clinical criteria listed for each drug are met.

Drug-specific reserved indications or required criteria: Each listed drug entry includes one of: reserved for documented allergic reaction to equivalent generic; reserved for inadequate response to preferred dosage forms or specified number of preferred products; reserved for specific indications (e.g., opioid‑induced constipation) or refers to a HealthPartners prior authorization PDF for detailed clinical criteria.see individual drug entry links

Provider must follow the linked HealthPartners PA PDFs where provided

NOXAFIL — Reserved indications / prior therapy

NOXAFIL products — coverage reserved when ALL of the following are met

NOXAFIL authorization criteria: 1) Diarrhea caused by Giardia lamblia with failure of metronidazole OR 2) Diarrhea caused by Cryptosporidium; some formulations reserved for documented allergic reaction to equivalent generic.

See NOXAFIL product entries and linked criteria.

NUZYRA — Infectious disease specialist and treatment failure required

NUZYRA — coverage reserved when ALL of the following are met

NUZYRA authorization criteria: 1) FDA‑approved indication; AND 2) Prescribed by or in consultation with an Infectious Disease provider; AND 3) Inadequate response to standard treatments or medical contraindication to their use; culture and sensitivity results required.

See NUZYRA REQUIRED CLINICAL CRITERIA.

OCALIVA — Safety/coverage advisory

OCALIVA — coverage guidance

OCALIVA guidance: Health care professionals should stop prescribing Ocaliva; patients should contact their clinician about stopping Ocaliva and starting alternative treatments. See the Primary Biliary Cholangitis policy for details.

OCALIVA statement per REQUIRED CLINICAL CRITERIA.

Pediatric reservations

OPFOLDA / OPIPZA pediatric reservation

Pediatric reserve: For children 6 years of age and younger, medication is reserved for prescribing by Behavioral Health providers or for patients previously stable on therapy; multi‑source brand products reserved for documented allergic reaction to generic when specified.age <=6

See OPFOLDA/OPIPZA REQUIRED CLINICAL CRITERIA and linked miglustat PDF.

The medications listed in this document are designated nonpreferred and are subject to the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization criteria. Coverage is granted only when the applicable prior authorization or the product‑specific required clinical criteria are met; absence of required documentation or failure to meet the linked criteria may result in noncoverage or denial.

Some entries in the list are explicitly reserved for use only within their FDA‑approved indications or require fulfillment of externally posted HealthPartners required‑clinical‑criteria PDFs. Examples include products where the entry is labeled “Reserved for FDA‑approved indications” and medications for which a separate required clinical criteria webpage is referenced.

Certain products are limited to FDA‑approved indications and defined patient populations; for example, CHOLBAM is reserved for specialist prescribing in patients with specified bile‑acid synthesis disorders or adjunctive use in select peroxisomal disorders, with dosing, weight documentation, and time‑limited authorizations specified.

CHOLBAM is reserved for prescribing by a specialist for patients with defined metabolic disorders (single enzyme defects or specified peroxisomal disorders), requires patient weight to verify dosing, and authorizations are provided for 6 months with reauthorization tied to demonstrable improvement in liver function.

Per‑entry restrictions vary: many drug lines include reservation language such as specialist prescriber requirement, limitation to patients with a documented allergic reaction to the equivalent generic, or requirement for inadequate response to preferred dosage forms. Providers must consult each drug’s individual "REQUIRED CLINICAL CRITERIA" statement or linked HealthPartners PDF for the precise per‑entry restrictions.

Some approvals include explicitly limited approval durations. Example: fidaxomicin (DIFICID) approvals are limited to 10 days for Clostridioides difficile infection where reserved criteria apply; GATTEX initial approvals are provided for 3 months with reauthorization options up to one year when reauthorization requirements are met.

Certain brand or multi‑source formulations are reserved only for members with a documented allergic reaction to the equivalent generic. Where that language appears, coverage of the brand or alternative formulation is contingent on documentation of the allergy.

Some medications are reserved for clinical‑trial‑level use or limited programs where approvals are provided only for patients who meet trial inclusion/exclusion criteria and have tried and failed specified alternatives; these entries reference the applicable required clinical criteria or study‑eligibility language.

Where reservation language states coverage is limited to patients with a documented allergy to the generic or with an inadequate response to preferred products, the payer requires documentation of the allergy or prior trials/failures as part of the prior authorization request.

Examples of brand or multi‑source reserved items include formulations that will only be approved for members with a documented allergic reaction to the equivalent generic; these entries explicitly restrict routine coverage of the brand product absent allergy documentation.

This extract does not state any blanket exclusions that remove coverage for broad classes of care; instead, coverage is managed through per‑drug prior authorization requirements and reserved‑use language. Individual drug entries may contain specific exclusions or limits referenced in their linked clinical criteria.

There are no universal, document‑level exclusions listed in this excerpt beyond the general rule that nonpreferred medications are not covered unless the applicable prior authorization or required clinical criteria are satisfied.

Many entries include entry‑level restrictions such as reservation for documented allergic reaction to the equivalent generic, requirement for prior inadequate response to preferred products, specialist prescriber requirements, or pediatric‑specific limitations. These per‑entry restrictions determine approval on a drug‑by‑drug basis.

Examples of reserved language applied at the entry level include approval only for patients with a documented generic allergy or only after failure of preferred therapies; without such documentation the nonpreferred product is not supported under the listed PA criteria.

Provider Actions — Prior Authorization & Documentation

Prior Authorization

Prior authorization and required clinical criteria

These medications require prior authorization per the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; many entries reference HealthPartners required clinical criteria PDFs or specialty coverage documents that must be met and submitted with the PA request.

Follow the MHCP Non-Preferred Drug PA criteria linked for each drug when listed.
If a HealthPartners required-clinical-criteria PDF or URL is shown for a product, include the requested documentation per that link.

Prior Authorization

Non-Preferred Drug Prior Authorization

Non-preferred medications listed are subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; prior authorization must be obtained and the drug-specific required clinical criteria satisfied to avoid denial.

Check the individual drug line for a link to the HealthPartners required clinical criteria or the MN DHS Nonpreferred PA PDF.
Submit documentation that meets the linked required clinical criteria when requesting PA.

Prior Authorization

MHCP Non-Preferred Drug Prior Authorization Requirement

Many listed medications are nonpreferred and subject to Minnesota DHS (MHCP) Non-Preferred Drug Prior Authorization Criteria; providers must request PA per MHCP criteria or the product's referenced HealthPartners criteria.

If the entry flags MHCP criteria, follow the MN DHS Non-Preferred Drug PA document.
Include any specialty or disease-specific PDFs linked on the product line with the PA submission.

Prior Authorization

FDA‑indication / external criteria PA

Certain medications are reserved for FDA‑approved indications or require meeting specific HealthPartners coverage PDFs or other external clinical criteria; include the referenced external criteria with the PA.

If the product line states "Reserved for FDA‑approved indications" or lists a HealthPartners URL, include the supporting documentation required by that link.
Off‑label uses are not covered unless the linked required clinical criteria allow them.

Prior Authorization

Prior authorization required for non-preferred drugs

These non-preferred medications require prior authorization per the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; many entries include a HealthPartners required-clinical-criteria link that must be followed.

Locate and include the product-specific required clinical criteria PDF or URL noted on the drug line.
PA requests that do not meet the referenced criteria risk denial.

Prior Authorization

Nonpreferred drug prior authorization requirement

Many products listed are nonpreferred and require prior authorization under MHCP Non-Preferred Drug PA Criteria; providers must meet the per-drug 'REQUIRED CLINICAL CRITERIA' (specialist prescriber, allergy documentation, prior trials, etc.).

Review each drug's required clinical criteria and include specialist notes when the entry requires a specific prescriber type.
Document allergic reactions to generics or prior trial failures when those reservation conditions are listed.

Prior Authorization

Nonpreferred drug PA required (including DIFICID specifics)

Nonpreferred drugs are subject to MHCP Non-Preferred Drug PA and some entries include specific limits — e.g., DIFICID approvals are limited to 10 days and require a diagnosis of C. difficile with inadequate response or contraindication to vancomycin.

For fidaxomicin (DIFICID): diagnosis of C. difficile infection and inadequate response or contraindication to vancomycin; approvals limited to 10 days.
Follow the linked required clinical criteria for exact documentation needs.

Prior Authorization

DIFICID PA specifics (fidaxomicin limited to 10 days)

Approvals for DIFICID (fidaxomicin) are limited to 10 days and require a diagnosis of C. difficile infection plus inadequate response or medical contraindication to vancomycin.

Include documentation of C. difficile diagnosis and prior vancomycin treatment and response.
PA duration will be limited to 10 days per the required clinical criteria.

Prior Authorization

Prior authorization required for nonpreferred drugs (E segment)

Prior authorization is required for the listed nonpreferred medications; where indicated, follow the Minnesota DHS Non-Preferred Drug PA criteria and include any HealthPartners required-clinical-criteria PDFs linked for the product.

Use the MHCP Nonpreferred PA PDF when the drug line flags MN DHS criteria.
Attach the HealthPartners PDF noted on the drug entry when present.

Prior Authorization

MHCP Non-Preferred Drug Prior Authorization

These listed medications are nonpreferred and subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; prior authorization must be obtained using the referenced criteria and linked HealthPartners documents.

Verify whether MHCP criteria or a HealthPartners required‑clinical‑criteria PDF applies and provide the requested documentation.
Failure to follow the linked criteria may result in denial.

Prior Authorization

Nonpreferred drug prior authorization requirement

These drugs are classified as nonpreferred and require prior authorization under Minnesota DHS Non‑Preferred Drug PA Criteria; follow the product-specific required clinical criteria linked in the entry.

Follow the URL provided for each drug's required clinical criteria.
Include requested lab results, diagnoses, or specialist notes as specified by the link.

Prior Authorization

GATTEX prior authorization rules (initial 3‑month approval; reauth up to 1 year)

GATTEX initial approvals are granted for three months; reauthorizations up to one year require documented reduction in parenteral nutrition (PN) volume and other eligibility documentation.

GATTEX criteria: adult short bowel syndrome with chronic PN requirements (e.g., ≥4 L/day), PN dependence ≥1 year and ≥3 days/week.
Initial approval = 3 months; reauthorization up to 1 year with documented PN volume reduction.

Prior Authorization

Prior authorization required for many non‑preferred drugs

Prior authorization is required for many listed non-preferred medications; follow the Minnesota DHS Non-Preferred Drug PA Criteria or the HealthPartners required clinical criteria URL provided per product.

Check each drug line for MHCP flag or HealthPartners PDF and include the specified documentation.
PA must demonstrate the member meets the per‑drug required clinical criteria to avoid denial.

Prior Authorization

Non-Preferred Drug Prior Authorization (general)

Prior authorization is required for the listed non-preferred medications; many entries point to the Minnesota DHS Non-Preferred Drug PA Criteria and specific HealthPartners prior‑auth documents that must be satisfied.

Include the linked HealthPartners required clinical criteria where present.
If MHCP criteria apply, follow the MN DHS Nonpreferred PA PDF for required elements.

Prior Authorization

Prior authorization required

Prior authorization is required for listed nonpreferred medications; prescribers must follow the Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria or the specific HealthPartners coverage criteria linked on the drug entry.

Attach required clinical documentation and any specialist consult notes referenced by the drug's criteria.
Requests missing the referenced documentation risk denial.

Prior Authorization

Lanreotide initial approval duration and continuation

Initial approvals for lanreotide acetate (Somatuline Depot) are for six months; annual approvals thereafter may be granted for responders with demonstrated effect.

Lanreotide reserved for patients where surgery is not an option or not curative and who have failed one somatostatin analogue.
Initial approval = 6 months; continuation = annual for responders.

Prior Authorization

Prior authorization requirement (general)

Prior authorization is required for non‑preferred drugs listed; many items are subject to Minnesota DHS Non‑Preferred Drug PA and require submission of the product‑specific required clinical criteria.

Include the HealthPartners required‑clinical‑criteria PDF when linked.
Document prior trials, allergies, or specialist involvement as specified on the drug line.

Prior Authorization

Prior authorization required for non‑preferred drugs (detailed)

Specified medications are non‑preferred and require prior authorization under Minnesota DHS Non‑Preferred Drug PA criteria; many individual entries list reserved indications or direct to HealthPartners prior‑auth PDFs for required clinical criteria.

Follow the drug‑specific required clinical criteria linked in each entry.
Provide documentation of inadequate response to preferred products or allergy to generics when required.

Prior Authorization

NOXAFIL prior authorization and reserved indications

Certain NOXAFIL formulations are nonpreferred and require prior authorization; indications include Giardia after failure of metronidazole or Cryptosporidium, and some forms are reserved for documented allergy to the generic.

NOXAFIL packet/suspension/tablet: reserved for Giardia after metronidazole failure or Cryptosporidium per the NOXAFIL required clinical criteria.
Some formulations are reserved for documented allergic reaction to the equivalent generic.

Prior Authorization

NUZYRA prior authorization requirements

NUZYRA is nonpreferred and requires meeting all three conditions: FDA‑approved indication, prescribed by or in consultation with an Infectious Disease provider, and inadequate response or contraindication to standard treatments with culture/sensitivity results.

Submit culture and sensitivity results and documentation of inadequate response to standard therapies.
Confirm Infectious Disease prescribing or consult is documented in the PA request.

Prior Authorization

OCALIVA prior authorization / safety advisory

HealthPartners advises clinicians to stop prescribing Ocaliva; see the Primary Biliary Cholangitis policy for coverage details — Ocaliva is nonpreferred and new starts may not be approved.

Refer to the PBC policy linked on the Ocaliva entry for specific coverage guidance.
Prescriptions contrary to the stop‑prescribing guidance may not be approved.

Prior Authorization

Pediatric prior authorization references (children ≤6)

Some pediatric entries (e.g., OPFOLDA, OPIPZA) include reservations for children ≤6 years; follow the referenced miglustat PDF or other pediatric criteria documents for exact prior authorization requirements.

For children 6 years and younger, check whether prescribing must be by Behavioral Health providers or if the patient must be previously stable on therapy.
Include the miglustat PDF or other pediatric criteria linked with the PA request.

Step Therapy

Step and failure (step‑therapy) requirements

Several agents are reserved for members after inadequate response to preferred products (often defined as failure of two or more preferred products) or when medical contraindications exist; document prior trials or contraindications in the PA.

Document trials and outcomes for preferred agents (number of failures stated where specified).
If a medical contraindication or allergy is claimed, include supporting clinical notes.

Step Therapy

Step therapy — failure of preferred products required

Many products require trial and failure of two or more preferred products or documentation of medical contraindication to preferred agents before the non‑preferred product will be authorized.

Provide dates and durations of prior therapies and clinical rationale for inadequate response.
If fewer trials are acceptable per a linked required‑clinical PDF, follow that document instead.

Documentation Required

Failure of preferred therapy or allergy documentation required

Several products are reserved for patients who have had an inadequate response to a preferred dosage form or who have a documented allergic reaction to the equivalent generic; include documentation of prior inadequate response or allergy.

For allergy claims, include records documenting the allergic reaction to the generic.
For inadequate response, include clinical notes demonstrating lack of efficacy on the preferred dosage form.

Step Therapy

Step or sequencing requirements — document prior trials

Many entries reserve product use for patients after inadequate response to two or more preferred products or when medical contraindications exist; include documentation of prior trials/failures or contraindication as specified.

Where 'two or more preferred products' is required, list each agent trialed and dates.
If a preferred product cannot be used due to contraindication, include clinician rationale and relevant labs/diagnoses.

Step Therapy

Required trials of preferred alternatives (step therapy)

Several agents require prior trials of preferred alternatives before approval; many migraine/triptan-related and other agents specifically require failure of two preferred alternatives.

For triptan-related agents, document failure of two preferred triptan medications as specified.
Include dates and objective response information to demonstrate inadequate benefit.

Documentation Required

Clinical justification and supportive documentation

Some products require documentation in the medical literature that they provide clinical benefit over preferred alternatives before approval; include any requested literature or specialist justification with the PA.

When the drug line asks for literature demonstrating benefit, attach relevant peer‑reviewed articles or specialist notes.
If the required clinical criteria PDF specifies what to submit, follow that instruction.

Documentation Required

Opioid attestation and short‑acting opioid trial documentation

Provider attestation is required for long‑acting opioids (including hydromorphone ER and fentanyl patches) confirming therapy is managed per standard opioid prescribing guidelines and that the patient had an inadequate response to an adequate short‑acting opioid trial (minimum 30 days continuous use).

Include signed provider attestation to opioid management per standard guidelines.
Document at least a 30‑day continuous trial of an appropriate short‑acting opioid and inadequate response prior to long‑acting opioid PA.

Documentation Required

External criteria and documentation links — include referenced PDFs

Include external HealthPartners required‑clinical‑criteria PDFs or URLs referenced on the drug entry with the PA request; providers must supply the documentation specified by those links.

Attach the exact HealthPartners PDF noted on the drug line (e.g., disease‑specific or specialty PA forms).
If a link is provided, ensure submitted documentation aligns with the fields/information requested in that document.

Documentation Required

CAYSTON documentation, quantity limit and renewal rules

For aztreonam inhalation (CAYSTON): initial approvals are for 12 months; renewals annually require documentation the patient has been seen within the last 12 months at a cystic fibrosis treatment center and that the medication is effective; quantity limit: one 28‑day package per month.

Prescribed and managed by CF treatment center specialists.
Attach documentation of CF center visit within past 12 months and clinical evidence of effectiveness for renewals.

Documentation Required

Required documentation examples to include with PA

Documentation examples required with PA requests include specialist prescribing notes, physician attestations (e.g., opioid management), evidence of prior trials/failures, documented allergic reactions to generics, and objective clinical measures where specified (e.g., slit lamp exam for CYSTADROPS/CYSTARAN).

Provide specialist notes when the product requires a specific prescriber type.
Include objective exam findings or lab results when the linked required clinical criteria requests them.

Documentation Required

Provide required clinical criteria PDFs and supporting docs

Providers must supply documentation consistent with the referenced required clinical criteria PDFs (e.g., Emflaza/deflazacort, immune thrombocytopenia, cancer‑drug PDFs) when requesting prior authorization.

If a drug lists a HealthPartners PDF, include the information requested in that PDF.
Failure to supply the linked required‑clinical documentation may result in denial.

Documentation Required

Required documentation per linked criteria (lab results, diagnoses, trials)

Provider must supply documentation meeting the referenced HealthPartners required clinical criteria PDFs or the Minnesota DHS Non‑Preferred Drug PA Criteria when requesting coverage for listed non‑preferred medications; this includes lab results, diagnoses, prior‑trial records, and specialist consults as specified.

Follow the specific document linked on the drug entry for the required fields and evidence.
Include culture/sensitivity, A1C, ICD‑10 codes, or other items only if requested by the linked criteria.

Documentation Required

Diabetes product documentation requirement (diagnosis proof)

For diabetes combination products (JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JENTADUETO XR) include documentation confirming a diagnosis of type 2 diabetes via one of: ICD‑10 code, medical records/chart notes, A1C or other lab results.

Attach one of: ICD‑10 diagnosis code for type 2 diabetes, chart notes, or A1C/lab results documenting type 2 diabetes.
If the drug line links a HealthPartners PDF, include the items requested there as well.

Documentation Required

Lanreotide documentation and approval duration

For LANREOTIDE ACETATE (Somatuline Depot): reserved for patients where surgery is not an option or not curative, and who have failed one somatostatin analogue; initial approvals are for six months with annual reapproval for responders.

Document prior somatostatin analogue trial and lack of surgical option/curative surgery.
Initial approval = 6 months; reauthorization annually for documented responders.

Denial Risk

Denial risk for missing PA or required documentation

Many listed nonpreferred medications carry denial risk if PA is not obtained or if the required clinical criteria and supporting documentation (e.g., trials, allergy, specialist attestations) are missing.

Requests lacking PA or required supporting documentation per the MHCP criteria or linked HealthPartners PDFs may be denied.
Verify and include all per‑drug required documentation to reduce denial risk.

Denial Risk

Nonpreferred drug PA denial risk

Use of nonpreferred medications without meeting MN DHS Non‑Preferred Drug PA criteria or the product's required clinical criteria may trigger prior authorization denial.

Confirm whether the MHCP Nonpreferred PA PDF applies and include requested evidence.
If the drug line specifies reserved conditions (allergy, prior failures), include documentation proving those conditions.

Denial Risk

Opioid attestation requirement and denial risk

Failure to provide required provider attestation for long‑acting opioids (that therapy is managed per standard opioid prescribing guidelines and prior short‑acting opioid trial ≥30 days) may lead to denial for fentanyl patches and other long‑acting opioid products.

Include a signed provider attestation confirming opioid management per standard guidelines.
Document a minimum 30‑day adequate trial of a short‑acting opioid and inadequate response when required.

Denial Risk

Nonpreferred drug PA risk — potential denials

Drugs flagged as nonpreferred are subject to Minnesota DHS Non‑Preferred Drug PA Criteria; lack of prior authorization or failure to meet required clinical criteria (e.g., allergy to generic, prior trials) may result in denial.

Obtain PA per MHCP Nonpreferred PA criteria when indicated.
Provide documentation of allergy, contraindication, or prior‑trial failures as required by the individual drug entry.

Denial Risk

NOXAFIL denial risk for missing reserved criteria

Use of NOXAFIL products without meeting reserved clinical criteria (e.g., failure of metronidazole for Giardia or specified Cryptosporidium criteria) or lacking documentation of allergy/inadequate response may trigger non‑coverage or PA denial.

For Giardia: document failure of metronidazole before NOXAFIL is considered.
Some NOXAFIL formulations are reserved only for documented allergy to the generic.

Denial Risk

NUZYRA denial risk — missing specialist/clinical evidence

NUZYRA requests without documentation of FDA‑approved indication, Infectious Disease prescriber/consultation, and inadequate response to standard treatments with culture/sensitivity results risk denial.

Attach culture and sensitivity results and documentation of prior standard‑therapy failure.
Document Infectious Disease involvement (prescriber or consult) in the PA.

Denial Risk

OCALIVA denial risk / safety guidance

Prescribing Ocaliva contrary to the stop‑prescribing guidance on the product line may not be approved; clinicians should refer to the Primary Biliary Cholangitis policy for coverage decisions.

Follow the PBC policy referenced on the Ocaliva entry for detailed guidance.
PA for Ocaliva new starts may be denied per stop‑prescribing recommendation.

Note

Initial Therapy Criteria and Approval Durations

Initial coverage conditions (partial)

Examples of initial coverage stipulations from extract

failure_of_preferred: Reserved for patients with an inadequate response to two or more preferred products or with medical contraindications to their use>=2 preferred failures

documentation and literature may be required

Specified initial approval durations

Examples of initial therapy/approval durations specified:

CYSTADROPS/CYSTARAN initial approval: Initial approvals will be provided for three months; renewals require documentation of clinical treatment effect and may be provided up to one year.initial = 3 months

See CYSTADROPS/CYSTARAN REQUIRED CLINICAL CRITERIA.

DALFAMPRIDINE ER initial approval: Initial approval will be for six months; patients showing documented improvement may be approved for one year thereafter with annual reapproval for continued positive response.initial = 6 months

See DALFAMPRIDINE ER REQUIRED CLINICAL CRITERIA.

Preferred trial requirements

Common initial therapy requirements found in this extract:

Preferred agent trial requirements: Many nonpreferred agents require trials of preferred alternatives (often two) or documented contraindication/allergy to preferred/generic agents before approval.often >=2 preferred failures

Based on multiple drug entries indicating 'Reserved for patients with an inadequate response to two preferred...' or 'Reserved for patients with a documented allergic reaction to the equivalent generic.'

GATTEX initial therapy

GATTEX initial therapy rules

Eligibility: Adult patients with short bowel syndrome with chronic parenteral nutrition >=4L/day, dependent >=1 year, PN >=3 days/week are eligible for GATTEX initial approval.PN >=4L/day; >=1 year; >=3 days/week

Initial approval: 3 months; reauthorizations up to 1 year with reduction in PN volume.

Initial therapy rules (select drug)

Initial approval durations when specified.

Lanreotide initial approval: Initial approvals are for six months for Somatuline Depot (LANREOTIDE ACETATE).6 months

Continuation annually for responders.

Lanreotide initial therapy

Lanreotide initial approval

Lanreotide initial approval: Initial approvals are for six months; annual approvals thereafter for responders.6 months

From LANREOTIDE ACETATE REQUIRED CLINICAL CRITERIA.

Initial authorization conditions

All initial therapy conditions: For many products, initial authorization is reserved for patients with documented allergy to equivalent generic or after inadequate response to one or more preferred products; for certain long‑acting opioids an initial trial of a short‑acting opioid (minimum 30 days) is required and provider attestation to opioid prescribing guidelines must be submitted.

See per‑drug required clinical criteria for specifics.

Continuation rules (select drugs)

Continuation criteria provided where specified (example: LANREOTIDE).

Lanreotide continuation: Annual approvals for responders with demonstrated effect after initial 6‑month approval.annual

From LANREOTIDE ACETATE REQUIRED CLINICAL CRITERIA.

Step Therapy — Required Trials & Documentation

Coverage requirement	Summary
Documentation of prior trials or contraindication required
Several entries state the non-preferred product is reserved for patients with an inadequate response to two or more preferred products or with medical contraindications; documentation in the medical literature of benefit over preferred alternatives may be required.

Coverage requirement	Summary
Trial and failure of preferred products required
Multiple drug entries require failure of one or more preferred products (often two) prior to coverage of the non-preferred product; applies to listed medications per their required clinical criteria.

Coverage requirement	Summary
Failure/inadequate response or documented allergy required
Some non-preferred products are reserved for patients who have had an inadequate response to a preferred therapy or who have a documented allergic reaction to the preferred generic; documentation required as noted in the entry.

Coverage requirement	Summary
Reserved after inadequate response to ≥2 preferred products or contraindication
Many entries explicitly reserve product use for patients who have had an inadequate response to two or more preferred products or who have medical contraindications to preferred therapies; documentation of prior trials is required.

Coverage requirement	Summary
Reserved for documented allergic reaction to equivalent generic
Numerous formulations and multi-source brand products are reserved only for patients with a documented allergic reaction to the equivalent generic; entries specify this exclusion unless allergy documented.

Coverage requirement	Summary
Document prior trials/failures or medical contraindications
Entries require documentation of prior trials/failures of preferred options or documentation of medical contraindications to preferred therapies; literature support may be requested for some agents.

Coverage requirement	Summary
Trial and failure of specified number of preferred agents
Certain agents (e.g., migraine/triptan-related drugs) require trial and inadequate response to a specified number of preferred agents (often two) before prior authorization is approved.

Coverage requirement	Summary
Document trials and responses per linked required clinical criteria
Providers must supply documentation consistent with the referenced HealthPartners required clinical criteria PDFs linked for individual drugs; prior trials and response details are collected per those documents.

Coverage requirement	Summary
Document prior inadequate response or contraindication
Some products are reserved for patients with prior inadequate response to preferred dosage forms or when medical contraindications to preferred agents exist; documentation required.

Coverage requirement	Summary
Provider attestation and meet MN DHS Non-Preferred Drug PA Criteria
Long-acting opioid products require provider attestation that therapy is managed per standard opioid prescribing guidelines (including prior trial of a short-acting opioid ≥30 days) and compliance with Minnesota DHS Non-Preferred Drug PA Criteria.

Coverage requirement	Summary
Meet clinical trial inclusion/exclusion criteria and guideline alignment
Some agents are reserved for use only when patients meet clinical trial inclusion/exclusion criteria and align with available guidelines; approvals may be time-limited (examples in entries).

Coverage requirement	Summary
Reserved for inadequate response to preferred products or allergy to generic
Multiple entries state products are reserved for patients with an inadequate response to preferred products or with a documented allergy to generic equivalents; documentation required prior to coverage.

Coverage requirement	Summary
Trial/failure of preferred products required when 'Reserved' language present
When an entry uses 'Reserved' language, trial/failure of preferred products (often one or two, sometimes specifically two) or documentation of contraindication/allergy is required; linked prior authorization documents may define exact step requirements.

Coverage requirement	Summary
Document prior trials or contraindications to preferred agents
Selected drugs (e.g., levofloxacin, levorphanol, L‑glutamine) require documentation of prior trials or failures of preferred alternatives or documentation of contraindication/allergy to generics as part of the required criteria.

Coverage requirement	Summary
Failure of preferred therapies documented prior to coverage
Numerous entries require documented failure of preferred therapies before the non-preferred product is covered; evidence of prior trials or clinical rationale must be provided per the entry.

Coverage requirement	Summary
Document prior trials or contraindications/allergies to preferred alternatives
Many products require documentation showing prior trials and inadequate response to preferred alternatives, or documentation of contraindication/allergy to preferred/generic options, before approval.

Coverage requirement	Summary
Prior trials of preferred agents or documentation of contraindication/allergy required
Specific products (examples: NOXAFIL formulations, NUDROXIPAK) note prior trials of preferred agents (or failure of first-line agents like metronidazole for Giardia) or documentation of allergy/contraindication are required before approval.

Quantity Limits

CAYSTON (aztreonam inhalation) — one 28-day package

ProductCAYSTON (aztreonam inhalation)

Quantity limitone 28-day package per month

Prescriber/siteMust be prescribed and managed by specialists from a cystic fibrosis treatment center

Initial approval durationInitial approvals will be provided for twelve months

Renewal requirementRenewals annually with documentation the patient has been seen within the last 12 months at the cystic fibrosis treatment center and the medication is effective

Site of Care Requirements

Billing Rule

ADASUVE: on‑site advanced airway management required

If ADASUVE is administered, the site must have on‑site access to equipment and personnel trained to provide advanced airway management including intubation and mechanical ventilation.

Documentation Required

CF specialty prescribing/management required for CAYSTON

Cystic fibrosis specialty therapies such as aztreonam inhalation (CAYSTON) must be prescribed and managed by specialists from a cystic fibrosis treatment center; initial approvals and renewals require CF center documentation.

Background

Purpose and scope: this document lists medications designated as nonpreferred by HealthPartners and specifies that these products require prior authorization per the Minnesota DHS Non‑Preferred Drug Prior Authorization criteria or the linked HealthPartners required clinical criteria. The extract summarizes common reservation patterns (allergy to generic, failure of preferred products, specialist prescriber requirements, and limited initial approval durations) and points providers to the individual drug entries or referenced PDFs for the exact required clinical documentation and numeric thresholds.

Definitions and Terms

Nonpreferred medication definition

TermNonpreferred medication

DefinitionA drug designated by the payer as nonpreferred on the formulary that requires prior authorization per Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria

ConsequenceRequests may be denied if prior authorization criteria are not met

Source guidanceMinnesota DHS Non-Preferred Drug PA Criteria referenced in multiple entries

Reserved use definition

TermReserved use

DefinitionCoverage limited to specific scenarios such as documented allergic reaction to equivalent generic, inadequate response to preferred products, or prescribing by a specified specialty

DocumentationDocumentation in the medical literature of clinical benefits over preferred alternatives may be required for some products

Reserved for inadequate response to preferred dosage form

TermReserved for inadequate response to preferred dosage form

DefinitionUse of the non-preferred product is permitted when a patient has failed or cannot use preferred dosage forms due to inadequate response or medical contraindication

Typical thresholdOften requires failure of two or more preferred products (where specified)

Reserved for documented allergic reaction to equivalent generic

TermReserved for documented allergic reaction to equivalent generic

DefinitionCoverage is limited to patients who have a documented allergy to the generic equivalent, supporting use of the branded or multi-source product

Applies toSeveral topical, oral, and other formulations listed in the document

MHCP Non-Preferred Drug Prior Authorization Criteria definition

TermMHCP Non-Preferred Drug Prior Authorization Criteria

DefinitionMinnesota Department of Human Services criteria that govern prior authorization for non-preferred drugs under MHCP; listed drugs require meeting these criteria or specific HealthPartners clinical criteria linked per product

Action requiredProviders must follow the linked MHCP PA criteria or HealthPartners required clinical criteria documents for each drug

Provider attestation (opioid products) definition

TermProvider attestation (opioid products)

DefinitionA signed statement by the prescriber that opioid therapy is being managed according to standard opioid prescribing guidelines and that required prior trials/criteria have been met

Typical requirementLong-acting opioids require attestation plus documentation of inadequate response to a recent adequate trial (minimum 30 days continuous) of a short-acting opioid

reserved for allergy to generic

Termreserved for allergy to generic

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

ExampleMultiple entries (e.g., CASGEVY, CEFACLOR ER) list this reservation condition

initial approval and renewal requirement example

ExampleInitial approval and renewal requirement (ophthalmic specialities) — e.g., CYSTADROPS/CYSTARAN initial approvals for three months with renewals requiring documentation of clinical treatment effect (slit lamp exam notes) and may be approved up to one year on renewal

Parallel exampleGATTEX initial approvals granted for three months; reauthorizations up to one year with documented reduction in parenteral nutrition volume requirements

PurposeEnsures clinical benefit and monitoring before longer-term authorization

Nonpreferred medication (term)

TermNonpreferred medication (term)

DefinitionA drug designated as non-preferred on the formulary that requires prior authorization per Minnesota Department of Human Services criteria

ImplicationSubject to linked required clinical criteria or MHCP Non-Preferred Drug PA criteria

Reserved for documented allergic reaction to generic (repeat)

TermReserved for documented allergic reaction to generic (repeat)

DefinitionUse of the listed brand or non-preferred product is permitted only when the patient has a documented allergy to the equivalent generic formulation

ExamplesCEFACLOR ER, CASGEVY and other entries list this condition

Inadequate response to preferred products (definition)

TermInadequate response to preferred products (definition)

DefinitionCoverage of the non-preferred product may be allowed when the patient has failed treatment with one or more preferred alternatives or cannot tolerate them; documentation of prior trials or contraindications is required

Typical thresholdOften requires failure of two or more preferred products where specified

Reserved (term)

TermReserved (term)

DefinitionLanguage used to indicate the drug is allowed only for patients with inadequate response to preferred dosage forms, medical contraindications to preferred products, or documented allergy to generic equivalents

ActionFollow the specific linked required clinical criteria for exact step/trial requirements per drug

Long-acting opioid attestation (definition)

TermLong-acting opioid attestation (definition)

DefinitionProvider attestation that therapy is managed per standard opioid prescribing guidelines and that the patient had an inadequate response to a recent adequate trial (minimum 30 days continuous use) of a short-acting opioid

Applies toLong-acting opioids and certain opioid-related products listed as nonpreferred (MHCP PA applies)

Reserved/Reserved for (term)

TermReserved/Reserved for (term)

DefinitionLanguage indicating a medication will be approved only for specified clinical indications, for patients failing preferred therapies, with contraindications, or with documented allergic reactions to generic equivalents

NoteSpecific per-drug required clinical criteria or HealthPartners PDF links define exact conditions