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Nonpreferred drugs list and required clinical criteria (partial)

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Lists nonpreferred medications subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria and points to required clinical criteria or specific HealthPartners coverage criteria documents; affects prescribers and pharmacists for HealthPartners members (MHCP/Minnesota).

Policy Summary

PayerHealthPartners

PolicyNonpreferred drugs list and required clinical criteria (partial)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization using the Minnesota DHS Non-Preferred Drug PA criteria and include required clinical documentation per the referenced HealthPartners criteria PDFs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+drug entries in this excerpt

multipleentries referencing external criteria

MNstate PA referenced

severalreserved-for-allergy/failure

Coverage Criteria for Nonpreferred Medications

Coverage Criteria for Nonpreferred Medications — Overview

Coverage of nonpreferred medications is subject to prior authorization (PA) per MHCP Non-Preferred Drug PA criteria and may also require drug- or product-specific conditions. Coverage is allowed only when the applicable TOP-LEVEL PA requirement and any listed product-specific criteria are met.

MHCP Non-Preferred Drug PA: The Minnesota Department of Human Services (MHCP) Non-Preferred Drug Prior Authorization Criteria must be met for MHCP (Minnesota Health Care Programs) members or when specified for MHCP Non-preferred products.

General reserved-use exceptions

Documented allergic reaction to the equivalent generic (or to individual active ingredients when combination product) documented in the medical record.
Inadequate response to preferred products: generally requires failure of one or more preferred alternatives; some drugs require failure of two or more preferred products (explicit when noted).

Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization required for nonpreferred drugs

Many medications listed are nonpreferred and require prior authorization (PA). For Minnesota Health Care Programs (MHCP), providers must follow the Minnesota Department of Human Services (MN DHS) Non-Preferred Drug Prior Authorization Criteria. When a HealthPartners coverage PDF or specific criteria link is referenced, the provider must submit documentation that meets those drug-specific criteria. Failure to meet MN DHS or HealthPartners prior authorization criteria may result in denial of coverage.

Nonpreferred drugs require PA under MN DHS Non-Preferred Drug PA Criteria.
Follow HealthPartners drug-specific prior authorization PDFs when referenced.

Documentation Required

DALFAMPRIDINE ER prior authorization and documentation

DALFAMPRIDINE ER is reserved for patients with multiple sclerosis who are currently able to walk 25 feet. Initial requests must include: neurologist prescribing, physician attestation that the patient has difficulty walking, documentation of ambulation (baseline), and dosing at no more than the FDA-approved 10 mg twice daily. Initial approval is for six months; continuation approvals require documented improvement in ambulation and may be approved for one year.

Step Therapy and Prior Trial Requirements

Documentation expectation	Source / notes
Documentation of prior trial(s) showing inadequate response to preferred therapy(s) or a documented medical contraindication/allergic reaction to preferred alternatives is required; in some cases clinical literature demonstrating benefit over preferred options is requested.
See product-specific entries and referenced HealthPartners or Minnesota DHS Non-Preferred Drug PA criteria for required supporting documentation and examples.

Step therapy example	Key requirement / source
Some nonpreferred agents are reserved until the member has had an inadequate response to preferred therapies (often two or more preferred products).
Long-acting opioid formulations require provider attestation of opioid management per standard guidelines and documentation of a minimum 30-day adequate trial of a short-acting opioid prior to coverage.

Per-product requirement	Example / source
Documentation of prior trials of preferred agents or documentation of allergy/contraindication to preferred agents as specified per product is required.
Examples include brivaracetam (requires inadequate response to two or more preferred seizure medications, one of which must be levetiracetam) and multiple topical agents reserved after trials or allergy documentation.

Threshold / trial requirement	Policy detail / citation
Typical threshold: documented trials of preferred alternatives (frequently two or more) or documented contraindication/allergy to preferred generics.
Many entries state coverage is reserved only after failure of two or more preferred products or when medical contraindications exist; documentation in the medical literature may be requested to support benefit over preferred alternatives.

Product-specific example	Required documentation
Diclofenac potassium powder pack — reserved for patients with inadequate response to two or more preferred triptan products AND two or more preferred NSAIDs.
Combination topical products — reserved when individual active ingredients failed separately due to documented allergic reaction (documentation of the allergic reaction required).

Key Clinical Thresholds and Coding Notes

DALFAMPRIDINE ER walking ability

Ambulation requirementMember must be currently able to walk 25 feet

Diagnosis requirementIndicated for patients with multiple sclerosis

Prescriber requirementPrescription must be by a Neurologist (neurologist prescribing)

DALFAMPRIDINE ER dosage limit

Maximum daily dosingNot more than 10 mg twice daily (FDA‑approved dosage)

Initial approval durationInitial approval granted for six months

Renewal condition

Billing, Site-of-Care and Special Billing Notes

Billing Rule

Insulin pump billing: bill through DME; PA not required when billed via DME

Follow the per‑drug billing and documentation notes for items with special billing rules (e.g., insulin pumps such as MINIMED must be billed through a DME provider as a medical claim; PA is not required when billed via DME).

Bill specified insulin pumps (e.g., MINIMED/T:SLIM X2) through a DME provider as a medical claim
PA not required when pump is billed through a DME vendor

Billing Rule

MINIMED insulin pump — DME billing and PA exemption

HealthPartners requires specified insulin pumps (example: MINIMED) to be billed through a durable medical equipment (DME) provider as a medical claim; when billed through DME, prior authorization is not required.

Background and Scope

This excerpt lists numerous branded medications designated nonpreferred under HealthPartners pharmacy coverage and directs clinicians to the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria and to HealthPartners coverage pages or PDFs for product‑specific clinical criteria and documentation requirements.

Nonpreferred: a medication designation indicating the drug is subject to the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria and typically requires prior authorization or other documented clinical justification (e.g., documented allergy to generic, failure of preferred products, or meeting product‑specific HealthPartners criteria) for coverage.

Definitions and Glossary

Nonpreferred

DefinitionMedication designated as 'nonpreferred' is subject to Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria

Coverage implicationCoverage requires meeting referenced MHCP/DHS PA criteria or specific HealthPartners clinical criteria when provided

Common actionsPrior authorization submission with supporting clinical documentation is required for nonpreferred drugs

Reserved

Definition'Reserved' indicates use limited to specific circumstances such as documented allergic reaction to the equivalent generic, inadequate response to preferred products, or specialist prescribing

ExamplesIncludes specialty-only prescribing (e.g., behavioral health for certain pediatric agents) and FDA‑indication‑only use

Policy Summary

PayerHealthPartners

PolicyNonpreferred drugs list and required clinical criteria (partial)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization using the Minnesota DHS Non-Preferred Drug PA criteria and include required clinical documentation per the referenced HealthPartners criteria PDFs.

SourceLink

On This Page

Medical contraindication to all preferred alternatives, with clinical rationale.

Drug limited to FDA-approved indication or restricted to trial-aligned use where specified (coverage only for FDA indication or trial-aligned population).

Specialist prescribing requirement when specified (e.g., oncology, neurology, behavioral health, or other specialist as noted in drug-specific criteria).

Selected Drug-Specific Failure Criteria

Selected drug-specific failure, reserved-use, allergy/contraindication, and long-acting opioid criteria (consolidated examples). Coverage is allowed only when ALL applicable conditions are satisfied for the listed product.

Selected drug-specific failure criteria

Brivaracetam (BRIVARACETAM / BRIVIACT): reserved for patients with an inadequate response to two or more preferred seizure medications, one of which must be levetiracetam.
DIFICID (fidaxomicin): reserved for patients with C. difficile infection and inadequate response or contraindication to one or more courses of vancomycin; approvals limited to 10 days.
Endari / L-Glutamine (Sickle Cell Disease drugs): reserved for patients meeting all of the following — diagnosis of sickle cell disease; age ≥5 years; two or more painful crises in prior 12 months despite continuous hydroxyurea (unless contraindicated); prescribed within FDA dose; meet MHCP Nonpreferred Drug PA criteria; initial and reauthorizations for 12 months with evidence of positive impact (reduced painful crises).
Dalafampridine ER: reserved for patients with multiple sclerosis who can walk 25 feet, physician attestation of walking difficulty, prescribing by a neurologist, and use not exceeding FDA-approved dosing; initial approval 6 months, then annual renewals for responders.
DIFICID (fidaxomicin) and other C. difficile agents: require prior failure of vancomycin except when contraindicated.
Tapentadol ER / Nucynta ER / other long-acting opioids: reserved for patients who have tried and failed two preferred products OR as otherwise specified; long-acting opioid attestation required (see Long-acting opioids node).

Long-Acting Opioid Criteria

Long-acting opioid coverage conditions (applies to fentanyl patches, methadone products, oxycodone ER, hydromorphone ER, tapentadol ER, and similar formulations where noted).

Long-Acting Opioid Requirements

Provider attestation that the patient's opioid therapy is being managed per standard opioid prescribing guidelines.
Documentation of an inadequate response to a recent adequate trial (minimum of 30 days of continuous use) with a short-acting opioid prior to initiating the long-acting formulation, unless clinically contraindicated.
For MHCP Non-preferred long-acting opioid products, the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria must also be met (link: https://mn.gov/dhs/assets/nonpreferred-drug-PA-criteria_tcm1053-379166.pdf).
Additional per-product notes
- Fentanyl patches: require the long-acting opioid attestation and MHCP Non-preferred PA; fentanyl citrate reserved for breakthrough cancer pain in opioid-tolerant patients who have tried and failed two preferred products or have contraindications.
- Methadone formulations (tablets, oral concentrate): require attestation and MHCP Non-preferred PA; some methadone products also permit coverage for documented allergy to generic equivalents as noted.
- Oxycodone ER / Oxycontin / Oxymorphone ER: require attestation and MHCP Non-preferred PA as specified for long-acting opioids.

Allergy, Prior Failure, and Specialist Reserved Uses

Allergy, contraindication, specialist-prescribing, and other reserved-use examples that commonly permit coverage of nonpreferred products.

Allergy or prior-failure exceptions

Documented allergic reaction to the equivalent generic (or to individual active ingredients for combination products) — many brand multisource entries are reserved for allergy to generic equivalents.
Inadequate response to preferred alternatives: where specified, coverage may require failure of one preferred product, two preferred products, or failure of preferred dosage form(s).
Inadequate response to a preferred dosage form or documented contraindication to preferred therapies — examples include topical steroid liquid vs cream formulations, GI formulations, or inhaled products where formulation matters.
Specialist-only use: certain drugs (e.g., oncology agents, cystinosis eye drops, complex biologics) are reserved for prescribing by a relevant specialist or require specialist attestation/documentation.

Drug-Specific Reserved Criteria (Examples)

Consolidated examples of drug-specific reserved criteria and required clinical links or documentation for coverage of listed nonpreferred drugs.

Drug-specific reserved criteria (examples)

Actemra / Cytokine & CAM antagonists: follow HealthPartners cytokine-and-CAM-antagonists prior authorization criteria (link provided in drug entry).
Arikayce: requires ARIKAYCE-specific PA criteria (link to HealthPartners ARIKAYCE criteria).
Cholbam: reserved for specialist prescribing in bile acid synthesis disorders due to single enzyme defects or as adjunctive treatment in peroxisomal disorders; dose and patient weight required; authorizations provided for 6 months and reauthorization based on liver function improvement.
Clobetasol cream/emulsion/spray: reserved for patients with inadequate response to two or more preferred products or with contraindication; literature documenting benefit required.
Colistimethate: reserved for specialist use in cases of resistant gram-negative pathogens.
Combination topical products (e.g., Clindamycin-benzoyl peroxide, Combogesic): reserved when individual active ingredients given separately have been tried and failed due to documented allergic reaction or inadequate response.
Fidaxomicin (DIFICID): reserved for C. difficile with prior inadequate response to vancomycin; limited duration approvals (10 days).
Endari and L-Glutamine: detailed Sickle Cell Disease criteria (see Selected drug-specific failure criteria node).
Nucynta ER / Tapentadol ER: reserved for patients who have tried and failed two preferred products; long-acting opioid attestation required.

Nonpreferred Drugs Requiring Referenced Clinical Criteria

Nonpreferred drugs that require referenced clinical criteria or additional documentation before coverage may be approved. Where an external HealthPartners or MHCP criteria link is cited in the drug entry, that referenced document governs the detailed requirements.

Nonpreferred drugs with required clinical criteria

When a drug entry references a HealthPartners coverage criteria document (e.g., oncology, cystic fibrosis modulators, clotting disorders, hereditary angioedema), the specific external criteria must be satisfied and are enforceable conditions of coverage.
Drugs limited to FDA-approved indications or use aligned with clinical trial inclusion/exclusion criteria (e.g., KYGEVVI, Orphan/rare disease therapies): must meet those indication-specific requirements and any additional duration/renewal conditions specified.
Medications reserved for pediatric or age-limited use (e.g., certain behavioral health ODT products): prescribing and age criteria must be met; some require Behavioral Health provider prescribing for children ≤6 years or other age thresholds.
Where the drug table indicates duration limits or reauthorization conditions (e.g., Endari, Cholbam, Dalafampridine), initial approvals and renewal requirements must be met and documented, including evidence of clinical benefit where required.
If MHCP Non-Preferred PA or a HealthPartners referenced PA is not met, coverage does not meet medical necessity and is subject to denial per coverage policy.

Required: MS diagnosis, ability to walk 25 feet, neurologist attestation, ambulation documentation.
Dose limit: ≤10 mg twice daily.
Initial approval duration: 6 months; renewals: up to 1 year with documented improvement.

Prior Authorization

Fidaxomicin (DIFICID) PA specifics

Some products have product-specific PA rules. Fidaxomicin (DIFICID) approvals are limited to 10 days and reserved for patients with a diagnosis of Clostridioides difficile infection who have had inadequate response to or contraindication to one or more courses of vancomycin. Provide diagnosis and prior treatment failure or contraindication documentation with the PA submission.

Approvals limited to 10 days.
Must document C. difficile diagnosis and prior inadequate response or contraindication to vancomycin.

Denial Risk

Opioid and fentanyl PA and attestation requirements

Long-acting opioids and fentanyl patches require special attestation and prior trial documentation. For long-acting opioid products (including fentanyl patches, hydromorphone ER, methadone, oxycodone ER, NUCYNTA ER, HYSINGLA ER, and similar agents), providers must attest that opioid therapy is being managed per standard opioid prescribing guidelines and document a recent adequate trial (minimum 30 days continuous use) of a short-acting opioid unless contraindicated. For fentanyl citrate, coverage is restricted to breakthrough cancer pain in opioid-tolerant patients who have tried and failed two preferred products or have documented contraindications.

Provider attestation required for long-acting opioids that care follows opioid-prescribing guidelines.
Document prior trial: minimum 30 days continuous short-acting opioid trial (unless contraindicated).
Fentanyl citrate: reserved for opioid-tolerant cancer pain after failure of two preferred products or contraindication.

Documentation Required

Documentation and evidence to support PA requests

Required documentation varies by drug. Common expectations include: diagnosis confirmation (ICD-10 code, chart notes, lab results), evidence of inadequate response to one or more preferred therapies (documented trials with duration), documented allergic reaction to equivalent generics when brand is requested, specialist prescribing or consultation where specified (e.g., Neurologist for DALFAMPRIDINE ER, ophthalmologist for CYSTADROPS/CYSTARAN), and objective measures of treatment effect for renewals (e.g., slit lamp exam notes for cystinosis drops, ambulation improvement for DALFAMPRIDINE ER). When a HealthPartners PDF or MN DHS criteria link is cited, include supporting materials that directly address those listed criteria.

Diagnosis and supporting labs or chart notes may be required (e.g., diabetes A1C for GLP-1/diabetes agents).
Document prior therapy failures (often two or more preferred products) or contraindications/allergies.
Specialist attestation required where specified (Neurologist, Behavioral Health, ophthalmology, etc.).
Include objective measures for renewals when requested (e.g., ambulation, slit lamp exam).
Follow drug-specific HealthPartners criteria links and include requested evidence.

Billing Rule

Billing notes and special submission instructions

Certain medications have billing or submission instructions that affect PA. Example: insulin pumps (e.g., ILET) must be billed through a DME provider as a medical claim; when billed through DME, PA is not required. CFTR modulators, testosterone products, and other specialty therapies may also have specific billing notes or MHCP requirements—consult the drug-specific criteria PDF.

Bill MINIMED/insulin pumps through DME as a medical claim; PA not required when billed via DME vendor.
Check drug-specific coverage PDFs for billing or submission instructions.

Step Therapy

Step therapy / prior-trial obligations

Step therapy and prior-trial requirements are common. Many nonpreferred products are reserved for patients who have had an inadequate response to preferred therapies — often two or more preferred products — or when specific prior agents (e.g., levetiracetam for brivaracetam) have failed. Document the trial(s), duration, and reason for discontinuation (lack of efficacy, intolerance, or contraindication). Some products are reserved for FDA-approved indications only or require sequencing (e.g., opioids: short-acting trial prior to long-acting).

Document trials and failures of preferred products (often two or more) when required.
Include duration and clinical rationale for failure or intolerance.
Adhere to any specific step sequence outlined in the drug criteria.

Documentation Required

Allergy, brand-reserved, and specialist-prescribed product documentation

Reserved-brand or allergy exceptions require clear allergy documentation. When a brand is reserved only for patients with an allergic reaction to the equivalent generic, submit medical record evidence describing the allergic reaction. For reserved uses (e.g., pediatric behavioral health products, cancer indications, or specialty agents), include provider specialty and prior stability documentation when applicable.

Allergy documentation required for brand-only coverage.
For pediatric BH-reserved drugs, indicate Behavioral Health prescribing or prior stability on the agent.
For cancer/specialty agents, include oncology documentation per referenced criteria.

Reserved-use example	Consolidated requirement
Multi-source brand products (e.g., diskets, certain topical combinations) — reserved for patients with a documented allergic reaction to the equivalent generic.
Brand or nonpreferred products are often reserved for use only after documented failure/inadequate response to preferred products or when a medical contraindication/allergy exists; supporting documentation required per product specifications.

Long-acting opioid step requirement	Required evidence
Provider attestation that opioid therapy is managed per standard opioid prescribing guidelines is required for long-acting opioid formulations.
Documentation of an adequate trial of a short-acting opioid for a minimum of 30 days of continuous use (and inadequate response) must be provided prior to coverage of long-acting opioids.

Diabetes agent requirement	Documentation expected
Certain diabetes agents (e.g., JANUMET, JANUMET XR, JANUVIA, JENTADUETO and JENTADUETO XR) require documentation confirming a diagnosis of type 2 diabetes.
Documentation may include ICD-10 diagnosis code, medical records/chart notes, A1C or other laboratory results as evidence of type 2 diabetes.

Failure of preferred dosage forms / alternatives	Policy note / examples
Approval frequently requires failure or inadequate response to a preferred dosage form or to two preferred alternative therapies where specified.
Examples include several oral and topical agents reserved after failure of two preferred products; product entries specify the required alternatives or dosage-form trials.

Prior trial and failure requirement	Operational implication
Many nonpreferred products require trial and failure of preferred agents or dosage forms before coverage is considered.
Providers must document prior therapies tried, reasons for failure/intolerance/contraindication, and any supporting clinical evidence per the product-specific criteria.

Prior trials examples	Source / note
Some agents are approved only after prior trial(s) of preferred alternatives or documented contraindication/allergy to preferred products (often two preferred products required).
Product entries frequently reference linked HealthPartners coverage criteria PDFs or the Minnesota DHS Non-Preferred Drug PA criteria for specific trial definitions and acceptable documentation.

Documentation summary for reserved products	Required elements
For reserved (nonpreferred) products, prior trials of preferred alternatives OR documentation of allergic reaction/medical contraindication to the preferred alternative are required.
Supporting documentation should follow the referenced HealthPartners criteria or Minnesota DHS Non-Preferred Drug PA criteria; some products also require specialist documentation or objective test results.

Reserved-use after failure / allergy	Consolidated examples
Many listed drugs are reserved for use only after trial and inadequate response to preferred products or when a documented medical contraindication or allergy to the preferred product exists.
Examples across the list include topical corticosteroids, neurologic agents, and other branded multisource products reserved for documented generic allergy or failure of preferred therapies.

Prior failure / contraindication required	Examples / note
Prior failure or contraindication to preferred alternatives is required for many nonpreferred drugs; the number and type of prior agents required (e.g., two or more) is specified per drug entry.
Providers should consult the specific drug entry or linked criteria PDF for the exact prior-therapy requirements and acceptable documentation.

Per-product prior treatment failures	Operational entry
Document prior treatment failures in the PA submission per the product-specific criteria (e.g., Talicia: failure to one first-line option; Tapentadol ER: failure of two preferred products).
Follow linked HealthPartners criteria or Minnesota DHS Non-Preferred Drug PA guidance for how treatment failure is defined and documented for each product.

Insulin pump / site-of-care billing note	Operational note
Certain insulin pumps (e.g., T:SLIM X2, Tandem devices) must be billed through a DME provider as a medical claim; prior authorization is not required when billed through a DME vendor.
Providers and billing staff should submit pump supplies and devices per DME billing instructions rather than pharmacy claim when applicable.

Annual renewal contingent on documented improvement in ambulation after six months

Short-acting opioid trial duration

Minimum trial durationMinimum of 30 days of continuous use of a short-acting opioid required

Provider attestationProvider must attest therapy is managed per standard opioid prescribing guidelines

ApplicabilityApplies to long-acting opioid products (e.g., fentanyl patches, methadone, morphine ER) designated nonpreferred

Testosterone deficiency threshold

Testosterone deficiency thresholdDocumented testosterone deficiency of less than 300 ng/dL required for coverage

Alternate pathwayCoverage may also be reserved for patients with a diagnosis of gender dysphoria

MHCP requirementFor MHCP nonpreferred products, must meet Minnesota DHS Non‑Preferred Drug PA Criteria

LDL threshold for Nexletol/Nexlizet

LDL thresholdLDL cholesterol >= 70 mg/dL required for Nexletol/Nexlizet coverage

Prior therapy requirementInadequate response to standard therapy (high‑intensity statin) or contraindication to statins required

Ezetimibe requirementInadequate response to ezetimibe or documented allergy/contraindication to ezetimibe required

Billing Rule

Billing and PA guidance for insulin pumps (T:SLIM X2 / MINIMED)

Billing instruction: certain insulin pumps (T:SLIM X2, Tandem devices, MINIMED) must be billed through a DME provider as a medical claim. When billed via a DME vendor, prior authorization is not required per HealthPartners notes in the policy.

Applies to T:SLIM X2 and other listed Tandem devices
PA exemption applies when billed through a DME vendor

DocumentationRequests must include documentation of the qualifying circumstance (e.g., allergy record, prior trials, specialist attestation)

Nonpreferred alternate phrasing

Alternate phrasing'Nonpreferred' is also described as a medication subject to MHCP Non‑Preferred Drug Prior Authorization Criteria in the document

ContextUsed interchangeably across entries to indicate PA requirements under Minnesota DHS criteria

ImplicationFailure to meet the referenced PA criteria may result in denial of coverage

Nonpreferred medication

Term use'Nonpreferred medication' denotes a drug requiring prior authorization per Minnesota DHS Non‑Preferred Drug PA Criteria and often additional documentation

Typical requirementsMay require prior trials of preferred agents, documentation of allergy, or specialist involvement depending on product

ConsequenceWithout meeting criteria, the request may be denied as not medically necessary under the nonpreferred rules

Opioid-tolerant (contextual)

Opioid‑tolerant (context)In context of fentanyl citrate for breakthrough cancer pain, 'opioid‑tolerant' implies prior opioid exposure consistent with tolerance and prior trials of preferred products

Required trialsFentanyl citrate reserved for opioid‑tolerant patients who have tried and failed two preferred products or have contraindications

DocumentationPrior trial documentation or contraindication evidence is required to support opioid‑tolerant designation

Reserved use

Reserved use reiterationIndicates the drug is limited to patients meeting specific conditions such as allergy to equivalent generic, inadequate response to preferred alternatives, or specialist prescribing

Provider actionProviders must supply documentation supporting the reserved condition (e.g., allergy record, prior trial notes, specialist attestation)

ScopeApplied across multiple product entries to restrict use to defined clinical scenarios

Nonpreferred

Nonpreferred (additional occurrence)Designation repeated throughout the list to indicate Minnesota DHS Non‑Preferred Drug PA Criteria apply

Associated requirementsMay reference specific HealthPartners coverage PDFs or MHCP PA links for product‑specific criteria

Denial riskUse without meeting the referenced criteria may result in coverage denial

Nonpreferred medication

Nonpreferred medication (additional excerpt)Repeated statement that listed medications are nonpreferred and subject to Minnesota DHS Non‑Preferred Drug PA Criteria

Product linksMany entries include links to HealthPartners required clinical criteria for specific drugs

Reserved conditionsSome entries additionally mark drugs as 'Reserved' for special circumstances (allergy, failure of preferred agents, FDA‑indication only)

Reserved

'Reserved' definition exampleIndicates drug use limited to FDA‑approved indications, trial‑aligned use, or patients meeting trial inclusion criteria or failing alternatives

Approval duration noteSome reserved uses include specified initial approval durations (e.g., 6 months) and renewal conditions

Documentation expectationProviders should follow linked criteria and supply evidence of trial failures or contraindications as required

Nonpreferred medication

Nonpreferred (additional occurrence)Designation used to denote medications subject to Minnesota DHS Non‑Preferred Drug PA Criteria and requiring PA when dispensed

Action requiredSubmit prior authorization per MN DHS criteria or linked HealthPartners clinical criteria document

Where to find criteriaHealthPartners public coverage‑criteria search page or product‑specific PDFs referenced in the list