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Nonpreferred Drug Prior Authorization List (MHCP Non‑Preferred Drug PA Criteria)

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List of nonpreferred medications subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization criteria and specific required clinical criteria or links; affects prescribers and pharmacies for HealthPartners members (MHCP).

Policy Summary

PayerHealthPartners

PolicyNonpreferred Drug Prior Authorization List (coverage criteria for MHCP nonpreferred drugs)

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 PA Criteria and submit required documentation or provider attestations (e.g., opioid attestation, prior trial history, allergy documentation) as specified for the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug entries shown in this extract

manyexternal criteria links

severalreserved for allergy to generic

severalrequires failure of preferred products

somelong-acting opioids needing attestation

Last updated 4/1/2026document timestamp

Coverage criteria and conditional coverage rules

General prior authorization criteria (examples)

Coverage is provided when required MHCP Non‑Preferred Drug Prior Authorization criteria are met per individual drug‑specific rules (examples shown in extract):

Examples of required conditions: (1) Documentation of inadequate response to preferred products (often two or more) OR documented medical contraindication to preferred products; (2) Documentation of allergic reaction to equivalent generic for multi‑source brand products when reserved for that reason; (3) When applicable, meet specific HealthPartners linked coverage criteria for diagnosis and dosing; (4) For certain pediatric antipsychotics, reserved prescribing by Behavioral Health providers or previously stable patients.

Extract shows these recurring requirement patterns across multiple drugs (see chunks 0-19).

Coverage conditional on MHCP / HealthPartners PA criteria

Coverage requires meeting MHCP Non‑Preferred Drug Prior Authorization Criteria or referenced HealthPartners coverage criteria where noted.

MHCP non-preferred PA: Medication is nonpreferred and coverage requires meeting the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria or the specific HealthPartners referenced coverage criteria.

Policy Summary

PayerHealthPartners

PolicyNonpreferred Drug Prior Authorization List (coverage criteria for MHCP nonpreferred drugs)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Applies to many drugs in this excerpt; see referenced PDFs for drug‑specific requirements

Class-specific coverage rules

Additional conditions for certain medication classes

Long-acting opioid criteria: Long‑acting opioids require provider attestation that management follows standard opioid prescribing guidelines and documentation of an inadequate response to a recent adequate trial (>=30 days) of a short‑acting opioid.>=30 days

Also subject to MHCP non‑preferred PA when applicable

Allergy exceptions: Some drugs are reserved for patients with a documented allergic reaction to the equivalent generic; documentation of the allergic reaction is required.

Referenced for multiple drugs

Covered with criteria (nonpreferred drugs)

Medications listed are nonpreferred and covered only when specific Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria and any HealthPartners‑required clinical criteria are met.

General

Opioid attestation: For long‑acting opioids: provider attestation that therapy is managed per standard opioid prescribing guidelines AND patient had inadequate response to a recent adequate trial (minimum 30 days continuous) of a short‑acting opioid30 days
Referenced in entries such as Conzip and general long‑acting opioid notes
Aztreonam inhalation (Cayston): Patient has cystic fibrosis with Pseudomonas aeruginosa in lungs AND prescription/management by CF treatment center specialist AND quantity limit up to one 28‑day package per month AND meets MN DHS nonpreferred PA criteriaone 28‑day package/month
Initial approvals 12 months; renewals annually with CF center visit and effectiveness documentation
Cholbam: Prescribed by a specialist for bile acid synthesis disorders due to single enzyme defects or as adjunct for peroxisomal disorders with liver manifestations AND prescribed at <=15 mg/kg/day (or 17 mg/kg/day for certain familial hypertriglyceridemia) AND patient weight provided to verify dose<=15 mg/kg/day
Authorizations for 6 months; reauthorization when liver function improves

Agent-specific required clinical criteria (example: dalfampridine ER)

Examples of specific coverage criteria present in excerpt:

DALFAMPRIDINE ER coverage: Reserved for patients with (1) multiple sclerosis, (2) currently able to walk 25 feet, (3) physician attestation that patient has difficulty walking, (4) prescribing by a Neurologist, and (5) at not more than the FDA approved dosage of 10 mg twice daily. Initial approval six months; continuation requires documented improvement in ambulation for yearly renewals.initial approval 6 months; renewal requires documented improvement

Requests approved yearly thereafter if positive response

Limited-duration approvals (example: fidaxomicin/DIFICID)

Agent‑specific reserved uses and limits:

DIFICID suspension coverage: Reserved for patients with (1) a diagnosis of clostridium difficile infection, and (2) inadequate response or medical contraindication to one or more courses of vancomycin. Approvals limited to 10 days.10 days

Allergic reaction exceptions

Allergic reaction / generic substitution exceptions:

Allergic reaction exception: Multiple branded agents are reserved for patients with a documented allergic reaction to the equivalent generic (examples: COSOPT PF, CYMBALTA reserved for allergic reaction to generic, various others).documented allergic reaction

Covered with criteria / Conditional coverage

Coverage of listed drugs is conditional on meeting specific required clinical criteria or referenced HealthPartners / Minnesota DHS prior authorization policies.

General PA requirement: Drug is non‑preferred and requires prior authorization under Minnesota DHS Non‑Preferred Drug PA Criteria or specific HealthPartners criteria link.

See linked PDFs for full criteria.

Exceptions recorded in list: Some drugs are reserved for patients with documented allergic reaction to equivalent generic OR inadequate response to preferred dosage form OR specific FDA‑approved indications (examples provided per drug entry).

Examples: FLECTOR, FLOMAX, FROVA, GATTEX, FIDAXOMICIN, GILENYA pediatric dosing.

Opioid-specific requirement: Long‑acting fentanyl patches require provider attestation that therapy follows opioid prescribing guidelines and that patient had inadequate response to a recent adequate trial (>=30 days) of a short‑acting opioid.>=30 days

Also for MHCP non‑preferred products, must meet MN DHS Non‑Preferred Drug PA Criteria.

Covered with criteria / reservation logic

Coverage/reservation conditions appearing in this excerpt

All other listed nonpreferred drugs: Subject to Minnesota DHS Non‑Preferred Drug PA Criteria; follow linked HealthPartners clinical criteria when provided.

See individual drug entry for specific reserved reasons or URLs

Reserved for documented allergic reaction to equivalent generic: Several entries (e.g., HARVONI 90‑400 mg tablet, HETLIOZ, certain long‑acting opioids) are reserved for patients with documented allergic reaction to the equivalent generic.

Document allergy to generic required

Reserved for inadequate response to preferred products: Multiple entries indicate reservation for patients with inadequate response to preferred dosage forms or to two or more preferred products or with medical contraindications.

Documentation of prior trials or contraindication required

Long-acting opioid-specific: Long‑acting opioids require a provider attestation that therapy is being managed per standard opioid prescribing guidelines and that patient had inadequate response to a recent adequate trial (minimum 30 days continuous) of a short‑acting opioid.minimum 30 days continuous short‑acting opioid trial

Also subject to Minnesota DHS Non‑Preferred Drug PA Criteria

L-Glutamine (endari) initial coverage criteria

Examples of reserved coverage conditions in this excerpt

L-Glutamine coverage: Member has Sickle Cell Disease AND age >= 5 years AND >=2 painful crises in prior 12 months despite continuous hydroxyurea (unless contraindicated) AND prescribed within FDA approved doseinitial & re‑authorizations for 12 months

Must also meet Minnesota DHS Nonpreferred Drug PA criteria

Antidiabetic agents documentation criteria

Documentation requirement for antidiabetic products in this excerpt

Janumet/Januvia/Jentadueto documentation: Reserved for diagnosis of an FDA‑approved indication AND documentation to confirm diagnosis of type 2 diabetes supported by one of: ICD‑10 code, medical records, chart notes, A1C or other lab result

Applies to Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR entries

Inadequate response / contraindication criterion

Generic reservation language present for multiple drugs

Reserved for inadequate response or contraindication: Medication reserved for patients with inadequate response to a preferred dosage form, or with medical contraindications to its use

Appears across many drug entries as a condition for coverage of nonpreferred formulations

Covered with conditions / product-specific criteria

Coverage for listed nonpreferred medications is conditional as indicated per‑product (examples below) when specified criteria are met

General nonpreferred coverage: Medication is covered when prior authorization per Minnesota DHS Non‑Preferred Drug PA Criteria is approved for a listed reason (e.g., documented allergic reaction to generic, inadequate response to preferred products, or medical contraindication).

See product‑specific entries for exact requirements.

L-GLUTAMINE specific: Member has sickle cell disease AND age >= 5 years AND >=2 painful crises in prior 12 months despite continuous hydroxyurea (unless contraindicated) AND prescribed within FDA‑approved dose AND meets MN DHS Nonpreferred Drug PA Criteria.

Initial & re‑authorizations for 12 months; renewals annually when originally authorized.

Long-acting opioids (e.g., methadone products): Provider attestation that opioid therapy is managed per standard opioid prescribing guidelines AND member had inadequate response to a recent adequate trial (>=30 days continuous use) with a short‑acting opioid; MHCP nonpreferred products must meet MN DHS Nonpreferred Drug PA Criteria.minimum 30 days

Applies to methadone formulations and methadose entries.

Products reserved for documented allergy to generic: Certain brand or multi‑source brand products are reserved for patients with a documented allergic reaction to the equivalent generic (example: LEXAPRO, LIPITOR, LOPID, LOVENOX entries).

Per‑product listing.

Products requiring failure of preferred alternatives: Many products require inadequate response to one or two preferred products or dosage forms, or contraindications to preferred products; documentation or literature supporting clinical benefit over preferred alternatives may be required (examples: LEVETIRACETAM SPRITAM, LEVOFLOXACIN, LEVORPHANOL, MARVONA SUIK).1-2 failed preferred products

Per‑product variation.

Long-acting opioids

Covered with prior authorization when specific criteria are met (examples from excerpt):

Long-acting opioid PA: Provider attestation that therapy is being managed per standard opioid prescribing guidelines AND patient had an inadequate response to a recent adequate trial (minimum 30 days of continuous use) with a short‑acting opioid; MHCP Non‑Preferred Drug PA Criteria must be met.30 days

Applies to listed long‑acting opioids (e.g., Methadose, Morphine ER, MS Contin)

Allergy or inadequate response exceptions

Covered with prior authorization when reserved clinical conditions are documented (examples from excerpt):

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

Used for many branded agents (examples: Micort‑HC, MS Contin, NEXIUM, NOXAFIL tablet/suspension)

Inadequate response to preferred: Reserved for patients with an inadequate response to a preferred product or preferred dosage form, or with medical contraindications to preferred products.failure of 1 or 2 preferred products as specified

Examples include Motofen (after two preferred generics), Miranow (inadequate response to two or more preferred products).

Cardiovascular agent escalation criteria

Agent‑specific LDL criteria (example):

Nexletol/Nexlize t criteria: Reserved for FDA‑approved indications AND inadequate response (LDL >= 70 mg/dL) to high‑intensity statins or contraindication to statins AND inadequate response to ezetimibe or documented allergy/contraindication to ezetimibe; approvals given for one year with reauthorization requiring LDL reduction attestation.LDL >= 70 mg/dL

Approval length: 1 year; reauthorization requires documented LDL reduction per provider attestation.

Coverage conditions for nonpreferred drugs (O–Oz segment)

Coverage for the listed nonpreferred medications is allowed only when required clinical criteria are met per the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria and any specific conditions listed per drug.

General condition for coverage: Drug is listed as nonpreferred and prior authorization is obtained per MN DHS Non‑Preferred Drug PA Criteria or HealthPartners required clinical criteria (linked PDFs)

Applies to all listed drugs in this segment

Drug-specific reserved conditions: Where specified, coverage is reserved for: documented allergic reaction to equivalent generic; inadequate response to two or more preferred products; medical contraindication to preferred alternatives; or FDA‑approved indication with specialist prescribing/consultation where required.

Drug entries include one or more of these reserved conditions; see individual drug line for details

Opioid-specific: Long‑acting opioids require provider attestation of adherence to opioid prescribing guidelines and prior inadequate response to a short‑acting opioid (>=30 days continuous), plus MN DHS Non‑Preferred Drug PA Criteria when applicable.30 days

Applies to oxycodone ER, OxyContin, oxymorphone ER and similar entries

Coverage criteria for listed nonpreferred drugs

Covered only when specific conditions or product‑specific criteria are met:

General PA requirement: Medication is nonpreferred and requires prior authorization under the Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria.

See external DHS criteria link referenced throughout.

Step therapy or allergy exceptions: Approval may be granted for patients with inadequate response to preferred products (often defined as failure of 1 or 2 preferred products), or documented allergic reaction/contraindication to equivalent generic or preferred dosage form.failure of 1-2 preferred products or documented allergy/contraindication

Many entries specify 'Reserved for patients with an inadequate response to two or more preferred products' or 'Reserved for patients with a documented allergic reaction to the equivalent generic.'

Product-specific requirements: Some products require product‑specific documentation or provider attestation (e.g., long‑acting opioids require attestation to opioid prescribing guidelines and prior short‑acting opioid trial; Ozempic requires documentation supporting diagnosis of type 2 diabetes such as ICD‑10 code, A1C, labs, or chart notes).see product‑specific links or notes

Multiple HealthPartners PDF links provided for product‑specific criteria.

Specialty program requirements: Certain specialty drugs reference separate HealthPartners coverage PDFs (e.g., cancer drugs, cystic fibrosis management) which contain the detailed criteria and approval durations (e.g., Pulmozyme initial approval 12 months, annual renewal with specialist visit documentation).see linked PDFs

Pulmozyme: initial approvals 12 months; renewals annually with documentation of specialist visit within last 12 months and effectiveness.

General reserved-use / prior authorization criteria (examples)

Coverage conditioned on one or more of the following reserved criteria as stated per drug entry or linked criteria documents

Reserved conditions examples: Examples across entries include: (1) documented allergic reaction to equivalent generic; (2) inadequate response to preferred dosage form or preferred products; (3) prescribing by or in consultation with a relevant specialist (e.g., allergist, neurologist); (4) patient stability previously on medication; (5) FDA‑approved indications only; (6) specific patient limitations (dexterity, vision, cognition, needle phobia); (7) specialty center management and recent follow‑up documentation.

Each drug may require one or more of these conditions; many entries point to an external required clinical criteria PDF for full logic.

Not eligible / withdrawn product

Explicit non‑coverage statement

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

Specific denial/not eligible condition.

Long-acting opioid coverage criteria

Opioid‑specific criteria

Long-acting opioid (Roxicodone): Coverage reserved for patients with documented allergic reaction to generic OR requires 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) with a short‑acting opioid.30 days

Attestation required for long‑acting opioid coverage.

Pulmozyme initial and renewal criteria

Specialty drug renewal criteria example

Pulmozyme (cystic fibrosis): Initial approvals provided for 12 months; renewals annually with documentation that the patient has been seen within the last 12 months at the cystic fibrosis treatment center and the medication is effective.12 months

Site‑specific specialty center follow‑up required for renewal.

Observed coverage criteria patterns

Coverage/authorization conditions vary by drug; common patterns include:

Nonpreferred requiring PA: Medication is listed as nonpreferred and is subject to Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria or specific HealthPartners coverage criteria (links provided).

See linked criteria for full logic

Reserved for allergy to generic: Reserved for patients with a documented allergic reaction to the equivalent generic or preferred product.

Appears for multiple multisource brand products (e.g., RYTARY, SABRIL, SANDIMMUNE, SEROQUEL).

Reserved after failure of preferred agents: Reserved for patients with an inadequate response to one or more preferred products or dosage forms, or with medical contraindications to preferred products.

Documentation of inadequate response required.

Specialist prescribing/consultation required: Some drugs are reserved for prescribing by or in consultation with specialty providers (e.g., infectious disease for SIRTURO; behavioral health for certain antipsychotics).

Follow specific drug‑level criteria.

Time-limited initial approvals: Certain agents have specified initial approval durations (e.g., SIGNIFOR initial 3 months; SOMATULINE and SOMAVERT initial 6 months) with annual renewals for responders.

Document response measures as indicated.

General reserved/required criteria (multiple drugs)

Coverage is restricted for listed nonpreferred medications and is reserved to patients meeting one of the specified criteria sets per product.

Reserved conditions (examples across entries)

Documentation for SYMLINPEN: 1) Reserved for diagnosis of an FDA‑approved indication; and 2) documentation to confirm diagnosis of type 2 diabetes supported by ICD‑10 code, medical records, chart notes, A1C or other lab result.
Talicia: Reserved for FDA‑approved indications and for patients with a treatment failure to one first‑line option. Treatment failure is defined as a positive fecal antigen test or endoscopy. First‑line options include triple or quadruple therapy.
Testosterone products (topical/injectable): Reserved for: (1) patients with a diagnosis of gender dysphoria OR (2) patients with an FDA‑approved indication with documented testosterone deficiency < 300 ng/dL; and for MHCP non‑preferred products, meet MN DHS Non‑Preferred Drug PA criteria.< 300 ng/dL
Insulin pumps (billing): HealthPartners requires certain insulin pumps to be billed through a DME provider as a medical claim; PA not required when billed through a DME vendor.
Opioid-related TAPENTADOL ER: Reserved for patients who have tried and failed two preferred products or with medical contraindications; long‑acting opioids require a provider attestation that therapy is managed per standard opioid prescribing guidelines, including failure after minimum 30 days recent adequate trial with a short‑acting opioid.minimum 30 days

Some products in this nonpreferred list are covered only for FDA‑approved indications. For example, AVONEX is explicitly reserved for FDA‑approved indications, and requests outside those indications require alternative authorization pathways or will not be approved under the nonpreferred PA rules.

Certain drugs are reserved for specific indications. As an example, betaine anhydrous is reserved for the FDA‑approved treatment of severe hyperhomocysteinemia and only for patients who have had an inadequate response to diet and vitamin supplementation with folic acid, vitamin B12, and vitamin B6.

Cholbam coverage is limited to clearly defined indications and dosing: authorization is reserved for patients with bile acid synthesis disorders due to single enzyme defects (SEDs) or as adjunctive treatment in specified peroxisomal disorders, and when prescribed at ≤ 15 mg/kg/day (with specified exceptions at 17 mg/kg/day in certain familial hypertriglyceridemia situations). Patient weight is required to verify dose and authorizations are time‑limited (authorizations provided for six months with reauthorization tied to liver function improvement).

The extract does not present blanket exclusions; instead, many entries use reserved for language to limit coverage to specified situations (for example, reserved for inadequate response to preferred products or for FDA‑approved indications), rather than listing explicit excluded products or circumstances.

Pediatric behavioral‑health prescribing restrictions appear in the list. For children ≤6 years, certain antipsychotic entries (e.g., ERZOFRI) are reserved either for prescribing by a Behavioral Health provider or for patients who were previously stable on the medication; multi‑source brand products in this category may also be reserved for patients with a documented allergic reaction to the equivalent generic.

Some fentanyl formulations are constrained to specific clinical scenarios. For example, certain fentanyl citrate products are reserved for breakthrough cancer pain in opioid‑tolerant patients and only after failure of two preferred products or when preferred products are medically contraindicated.

Several brand or multisource products are reserved only when there is a documented allergic reaction to the equivalent generic. The list includes multiple such examples (e.g., entries with 'Reserved for patients with a documented allergic reaction to the equivalent generic'), and the policy requires documentation of the allergic reaction to support coverage.

Levetiracetam examples: Keppra and Keppra XR are listed as nonpreferred but are specifically reserved for patients with a documented allergic reaction to the equivalent generic, which implies coverage is allowed only when that allergy is documented.

Many entries point reviewers to separate HealthPartners coverage criteria PDFs rather than embedding full criteria in the list. Where provided, these external documents define the detailed clinical requirements that must be submitted with a prior authorization request (for example cancer‑drug PDFs and other product‑specific prior‑auth PDFs referenced in the entries).

Some agents are explicitly reserved for their FDA‑approved indications only. For example, methoxsalen is reserved for its FDA‑approved indication (severe recalcitrant disabling psoriasis) after failure of standard therapies, and other entries similarly limit coverage to FDA‑approved uses or narrowly defined severe conditions.

Ocaliva is accompanied by a safety notice in the excerpt: Health care professionals are advised to stop prescribing Ocaliva and patients should contact their prescriber about stopping and starting other treatments. The entry refers reviewers to the Primary Biliary Cholangitis policy for more information.

The document does not assert any standalone coverage without prior authorization; nonpreferred medications in this list are subject to Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria or referenced HealthPartners clinical criteria, and coverage is contingent on meeting those criteria.

Relyvrio is explicitly listed as not eligible for coverage through HealthPartners as of 4/4/2024 because it has been withdrawn from the market; requests for Relyvrio are not eligible and will be denied.

Some specialty agents are reserved for defined specialty indications and patient pathways. For example, Somatuline Depot (lanreotide) is reserved for patients where surgery is not an option or not curative and who have failed one somatostatin analogue; initial approvals are time‑limited and renewals require documentation of response.

The policy repeatedly uses allergic‑reaction and inadequate‑response language to reserve brand products: multiple entries state coverage is allowed only for patients with a documented allergic reaction to the generic or after inadequate response to one or more preferred agents. These conditions require documentation to support the PA request.

The excerpt does not include explicit statements designating items as 'not medically necessary' (NMN). Instead, it focuses on nonpreferred status and on conditions under which coverage is allowed; absence of required PA documentation or meeting of specified criteria is implied to result in noncoverage.

Products marked as nonpreferred generally imply a prior authorization requirement. The document repeatedly references the Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria; when a product is nonpreferred or listed as 'Y', a PA per DHS criteria is required unless an alternative HealthPartners coverage criteria PDF is linked and satisfied.

No explicit 'not medically necessary' determinations are present in the extract; entries are characterized as nonpreferred and governed by PA rules rather than labeled NMN within the provided text.

Across the excerpt there are no blanket statements declaring entire classes of drugs as NMN. Instead, the policy restricts coverage by listing product‑specific reserved conditions, referring to external HealthPartners criteria, and requiring Minnesota DHS nonpreferred PA criteria where applicable.

There is no single blanket 'not medically necessary' statement in this excerpt. Coverage decisions are conditioned on meeting the listed reserved‑use or MN DHS nonpreferred PA criteria; use of a nonpreferred product without meeting those criteria would be considered not covered under this policy framework.

When a nonpreferred product is used without meeting the required Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria or any product‑specific required clinical criteria, the request may be denied. The policy explicitly links noncoverage risk to failure to meet DHS PA criteria or product‑level reserved conditions.

What providers and pharmacists must do

Prior Authorization

Prior authorization required

Prior Authorization Required: Many drugs listed as nonpreferred require prior authorization. For MHCP (Minnesota Health Care Programs) members, the Minnesota Department of Human Services (DHS) Non-Preferred Drug Prior Authorization Criteria also apply. Providers and pharmacists should verify PA requirements before prescribing or dispensing.

Check HealthPartners coverage criteria and product-specific PA forms: https://www.healthpartners.com/public/coverage-criteria/search.html
MN DHS Non-Preferred Drug PA criteria: https://mn.gov/dhs/assets/nonpreferred-drug-PA-criteria_tcm1053-379166.pdf

Step Therapy

Step therapy / failure of preferred agents

Step therapy / preferred-first requirements: For many nonpreferred agents a documented trial and failure (or contraindication or intolerance) of preferred alternatives is required. Where specified, failure should be documented as an adequate trial (often minimum 30 days continuous use) or as noted in the product-specific criteria.

Document prior trials (medication names, dates, duration, and reason for discontinuation) in chart notes
Some products require failure of specific preferred agents (see product line entries and linked criteria)

Documentation Required

Opioid attestation required

Long-acting opioids: Prior authorization plus a provider attestation is required for long-acting opioid products. The attestation must state that therapy is being managed per standard opioid prescribing guidelines and that the patient had an inadequate response to a recent adequate trial (minimum of 30 days continuous use) of a short-acting opioid. MHCP nonpreferred opioid requests must also meet MN DHS Non-Preferred Drug PA criteria.

Examples include fentanyl patches, Hysingla ER, Hydromorphone ER, Methadone formulations, Morphine ER, Oxycontin, Oxymorphone ER, Tapentadol ER, Nucynta ER, and others listed in the formulary
Include attestation statement in PA submission; attach supporting documentation of prior short-acting opioid trial

Documentation Required

Provide required clinical documentation

Documentation requirements: Provide clinical justification and supporting documentation with PA requests. This includes diagnosis confirmation (ICD-10, chart notes, labs such as A1C for diabetes agents), prior therapy details, specialist involvement when required, and any product-specific forms or checklists.

Attach culture/sensitivity for infectious disease agents when requested (e.g., Nuzyra)
Specialist prescribing or consultation required for certain agents (e.g., CF center for Cayston, infectious disease for TB drugs)
Product-specific documentation links are provided in the formulary entries

Prior Authorization

Follow product-specific PA & renewal rules

Product-specific PA notes and renewal conditions: Some medications have special PA conditions — for example, CF inhaled aztreonam (Cayston) requires prescribing/management by a cystic fibrosis treatment center and initial approval for 12 months with annual renewal documentation. Endari and L-glutamine for sickle cell disease have age, crisis frequency, hydroxyurea use, dosing, and renewal requirements.

Review product entry for duration of initial approval and renewal conditions
Include required weight or dosing information when requested (e.g., Cholbam weight to verify dose)

Billing Rule

Billing rule — insulin pumps / DME billing

Billing rules for insulin pumps and certain DME-associated drugs: HealthPartners requires specified insulin pumps (e.g., ILET insulin pump, T:SLIM X2, Tandem/T:SLIM kits) to be billed through a DME provider as a medical claim; prior authorization is not required when billed through a DME vendor.

Bill pumps and related supplies via DME medical claim pathway to avoid pharmacy PA where applicable
Confirm DME vendor billing procedures before submission

Denial Risk

Denial risk if criteria or documentation not provided

Denial risk & compliance: Failure to provide required MN DHS PA documentation or provider attestation, or to meet product-specific criteria (including step therapy/previous trials), will result in denial of the PA request. For MHCP members, noncompliance with DHS criteria increases denial risk.

Ensure all attestation statements and required documentation are included at submission
If denied, review criteria and provide additional clinical information or documentation for reconsideration

Key definitions and terms

Nonpreferred drug — definition

DefinitionA medication designated as nonpreferred and subject to the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; approval typically requires meeting specified clinical criteria or prior authorization.

Coverage implicationUse of a nonpreferred drug requires prior authorization under MN DHS Non-Preferred Drug PA Criteria; lack of required PA may lead to denial.

Source for drug-specific criteriaIndividual drug entries reference HealthPartners clinical criteria PDFs or the MN DHS Nonpreferred PA criteria for product-level requirements.

Nonpreferred medication — alternate extract

Alternate definitionA medication designated as nonpreferred on the formulary and subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria.

Common reserved reasonsOften reserved for inadequate response to preferred products, documented allergy to equivalent generic, or FDA‑approved indication only.

Documentation expectationProviders must supply documentation (e.g., prior trials, allergy documentation, specialist notes) per the referenced criteria.

MHCP Non-Preferred Drug Prior Authorization Criteria — definition

DefinitionMHCP Non-Preferred Drug Prior Authorization Criteria = Minnesota Department of Human Services criteria that govern prior authorization for nonpreferred drugs for Minnesota Health Care Programs members.

ApplicabilityApplies to medications designated nonpreferred in the HealthPartners/MHCP formulary; many entries in this list require meeting these criteria.

LinkageDrug-specific entries often reference the MN DHS Nonpreferred Drug PA Criteria URL for full prior authorization logic.

Nonpreferred medication — alternate

Restated definitionA medication designated as nonpreferred and subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria as listed by HealthPartners.

Implication for reviewersReviewers must confirm product-level reserved reasons (e.g., allergy to generic, step-therapy failures) and MHCP PA compliance before approval.

Where to find detailsSee individual HealthPartners drug entry or linked coverage PDFs for specific required clinical criteria and documentation instructions.

Initial & re-authorizations duration (L-GLUTAMINE example)

Initial & re-authorization durationInitial and re-authorizations for L-Glutamine (Endari) will be for 12 months.

Renewal conditionRenewals will be provided annually when originally authorized by HealthPartners, prescribed within FDA‑approved doses, and medication is effective.

Required clinical criteria summaryMember must have sickle cell disease, be ≥5 years old, have ≥2 painful crises in prior 12 months despite continuous hydroxyurea (unless contraindicated), and meet MN DHS Nonpreferred Drug PA Criteria.

Long-acting opioids — provider attestation (definition)

Attestation requiredProvider attestation that opioid therapy is being managed per standard opioid prescribing guidelines is required for long-acting opioids.

Trial requirementAttestation should document an inadequate response to a recent adequate trial (minimum 30 days continuous use) of a short-acting opioid.

MN DHS PAFor MHCP nonpreferred long-acting opioids, the MN DHS Non-Preferred Drug PA Criteria must also be met.

Reserved for documented allergic reaction to equivalent generic — definition

Exception conditionCoverage allowed only when the patient has a documented allergic reaction to the equivalent generic formulation.

Documentation requiredClinical documentation of the allergic reaction must be provided with the PA request.

ScopeUsed for multiple multi‑source brand products listed as reserved for allergic reaction to generic.

Provider attestation (long-acting opioids) — definition

Provider attestation contentA statement that therapy is being 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.

Use casesRequired for long-acting opioid authorizations (examples: fentanyl patches, OxyContin, Methadose) listed as nonpreferred.

Denial riskFailure to provide this attestation or required trial documentation may result in denial of the PA request.

Reserved — coverage limited to specified conditions

Reserved — general meaningMedication coverage is limited to patients meeting specified conditions such as inadequate response to preferred products, documented allergy to equivalent generic, specialist prescribing, or FDA‑approved indications only.

Examples of conditionsConditions include failure of preferred alternatives, documented contraindication/allergy, specialist management requirements, or stability on prior therapy.

Action for providersSubmit documentation per the listed reserved condition or follow linked HealthPartners criteria PDFs for product‑specific requirements.

Reserved for children ≤6 years (behavioral health prescribing restriction)

Age‑limited behavioral health restrictionFor certain antipsychotics, use in children ≤6 years is restricted to prescribing by Behavioral Health providers or for patients previously stable on the medication.

Multi‑source brand noteIf the product is multi‑source brand, additional reservation (e.g., allergy to generic) may apply as listed per drug entry.

Provider actionEnsure behavioral health prescribing or documentation of stability on therapy when requesting PA for children ≤6 years.

Treatment failure (Talicia) — definition example

Example definition of treatment failure (Talicia)Treatment failure is defined as a positive fecal antigen test or endoscopy after first-line therapy (triple or quadruple therapy) has failed.

Implication for TaliciaTalicia is reserved for patients with treatment failure to first-line options per the definition above.

Documentation to submitProvide test results (positive fecal antigen or endoscopy) and prior therapy details with the PA request.

Initial therapy coverage rules

Pediatric behavioral health prescribing

Pediatric/behavioral health prescribing exceptions

Pediatric antipsychotic exceptions: For children 6 years of age and younger, certain antipsychotic formulations are reserved for prescribing by Behavioral Health providers or for patients previously stable on the medication; multi‑source brand products reserved for documented allergic reaction to generic equivalents.

Seen for ABILIFY, ARIPIPRAZOLE ODT, ASENAPINE MALEATE entries.

Aztreonam (Cayston) initial therapy

Aztreonam inhalation initial approval rules

Aztreonam initial: Prescribed for CF patients with Pseudomonas aeruginosa; prescribed and managed by CF treatment center specialist; quantity up to one 28‑day package per month; meets MN DHS nonpreferred PA criteriaone 28‑day package/month

Initial approvals provided for twelve months

Cholbam initial therapy

Cholbam initial authorization rules

Cholbam initial: Prescribed by a specialist for specific indications (SEDs or adjunct for PDs with liver manifestations); dose <=15 mg/kg/day (or 17 mg/kg/day for certain familial hypertriglyceridemia); patient weight provided to verify dose<=15 mg/kg/day

Authorizations provided for 6 months

Initial approval examples

Initial approval constraints for select agents

CYSTADROPS/CYSTARAN initial: Initial approvals will be provided for three months for cystinosis treatments; renewals require documentation of clinical treatment effect.3 months initial

Lanreotide (Somatuline) initial therapy

Lanreotide specific initial approval rule

Lanreotide initial approval: Reserved for patients for whom surgery is not an option or has not been curative, and who have failed one somatostatin analogueInitial approvals are for six months; annual approvals thereafter for responders

Somatuline Depot specific

L-GLUTAMINE initial authorization

L-GLUTAMINE initial auth: Diagnosis of sickle cell disease; age >=5; >=2 painful crises in prior 12 months despite hydroxyurea (unless contraindicated); prescribed within FDA dose; meet MN DHS Nonpreferred PA criteria.

Initial auth for 12 months.

Opioid initial authorization

Long-acting opioid initial auth: Provider attestation of opioid management per guidelines AND minimum 30 days prior short‑acting opioid trial failed; meet MN DHS Nonpreferred PA criteria.30 days

Applies to methadone and methadose formulations.

Initial therapy examples

Initial authorization requirements (examples):

Testosterone products (e.g., Methitest/Methyltestosterone): Reserved for patients with an FDA‑approved indication and documented testosterone deficiency <300 ng/dL AND inadequate response to preferred topical testosterone product, OR diagnosis of gender dysphoria with inadequate response to preferred topical testosterone products.testosterone <300 ng/dL

From excerpt: Methitest / Methyltestosterone criteria.

Initial therapy requirements (examples)

Initial approval conditions for select products

Long-acting opioids initial requirement: Require provider attestation that therapy is managed per opioid prescribing guidelines and patient had an inadequate response to a recent adequate trial (minimum 30 days continuous use) of a short‑acting opioid.>=30 days short‑acting opioid trial

Also must meet Minnesota DHS Non‑Preferred Drug PA criteria for MHCP non‑preferred products.

Pulmozyme initial therapy

Pulmozyme initial approval

Pulmozyme initial: Initial approvals provided for twelve months when prescribed and managed by cystic fibrosis treatment center.12 months

Renewal requires annual documentation of specialist visit and effectiveness.

Time-limited initial approvals

Initial approval durations where specified:

SIGNIFOR initial approval: Initial approvals are for three months; annual approvals thereafter for responders with reduction in mean urinary free cortisol.

SOMATULINE/SOMAVERT initial approval: Initial approvals are for six months; annual approvals thereafter for responders with demonstrated effect.

Renewal and continuation rules

DALFAMPRIDINE ER continuation

Continuation requirements/example

DALFAMPRIDINE ER continuation: Patients continuing to meet criteria with documented improvements in ambulation after six months will be approved for one year; requests will be approved each year thereafter for patients who continue to have a positive response.documented improvement

Renewal/continuation rules (example)

Renewal condition for a listed specialty drug

Pulmozyme renewal: Renewals provided annually with documentation that the patient has been seen within the last 12 months at the cystic fibrosis treatment center and the medication is effective.annual specialist visit and effectiveness documentation

Initial approvals provided for twelve months.

Step therapy and prior trial requirements

Requirement	Notes / Examples
Trial and failure of preferred products is required
Many nonpreferred medications are reserved for patients with an inadequate response to two or more preferred products (or as specified per drug). See individual drug entries and linked HealthPartners/MN DHS PA criteria.

Requirement	Documentation
Document trial failures of preferred agents
Requests must include records demonstrating prior trials and inadequate response to preferred options; examples include seizure medications where two or more preferred agents (one must be levetiracetam) are required before brivaracetam is covered.

Requirement	Provider action
Provider attestation required for certain classes (long-acting opioids)
Provider must attest therapy is managed per standard opioid prescribing guidelines and document prior adequate short‑acting opioid trial (minimum 30 days continuous use); MHCP nonpreferred PA criteria also apply.

Condition	Coverage implication
Reserved after failure of preferred products
Many topical and oral agents are covered only for patients who have tried and failed preferred products or dosage forms, or when medically contraindicated; documentation required as noted per product.

Documentation requirement	When required / examples
Documentation of prior trials or contraindication to preferred products
Some entries require citation of medical literature if superiority to preferred alternatives is claimed; many require documentation of prior failures or medical contraindications (see per-product criteria).

Requirement	Per-product note
Prior trials of specified alternatives or documentation of allergic reaction to generic
Examples: certain combination topical pumps reserved when individual active ingredients failed or when documented allergy to generic exists; some oral agents reserved after failure of preferred alternatives.

Requirement	Documentation specifics
Document prior trials or contraindications as specified per drug entry
Examples include reserved use when patient failed Voltaren 1% topical gel (diclofenac cilexetil) or when oral/solution formulation preferred dosage failed (itraconazole), per-entry instructions apply.

Requirement	Follow-up
Document prior trial(s) of preferred products or documented allergy/contraindication
Follow HealthPartners or Minnesota DHS non-preferred PA criteria links where provided; long-acting opioids additionally require provider attestation of opioid management.

Policy pattern	Implication
Many nonpreferred products are reserved for patients who failed preferred alternatives or have contraindications
Coverage commonly requires prior authorization demonstrating inadequate response to preferred products or valid contraindication; documentation standards vary by product.

Provider obligation	Per-product requirement
Providers must document trials of preferred products or contraindications as specified per-product
Examples: Levetiracetam SPRITAM reserved when preferred dosage form failed; Pulmozyme renewals require documentation of specialist visit and effectiveness. See individual entries for details.

Coverage precondition	Required evidence
Documented trial/failure of preferred alternatives or documented medical contraindication/allergy before approval
Many products list 'reserved for' language—approval requires medical record evidence of prior trials, allergy documentation, or contraindication; see product entry and linked HealthPartners PDFs.

Requirement	Coverage note
Prior trials documentation or medical contraindication documentation required for coverage
Numerous entries require documentation that preferred alternatives were tried and failed (often two or more) or that a contraindication/allergy exists; documentation in literature may be requested for superiority claims.

Policy	Typical reserved reasons
Many entries reserve use for patients who failed preferred alternatives or have contraindications to them
Typical reserved reasons include inadequate response to one or two preferred products, documented allergic reaction to equivalent generic, or medical contraindication; see per-drug required clinical criteria.

Requirement	Resulting action
Trial/failure of preferred products before coverage of nonpreferred listed brand
Multiple entries explicitly state coverage is reserved until patient demonstrates inadequate response to preferred dosage form(s) or until allergy/contraindication is documented; PA required per MN DHS criteria.

Requirement	Reviewer expectation
Documentation of trial and failure or contraindication to preferred agents required prior to coverage of nonpreferred product
Reviewers expect clinical records showing prior trials and outcomes or clear evidence of contraindication/allergy; some entries reference external HealthPartners coverage PDFs for required documentation.

Requirement	Threshold / examples
Trial and failure of specified number of preferred products before nonpreferred approval
Some drugs require failure of two or more preferred products (varies by product); in several cases documentation that preferred options were tried and ineffective is necessary before approving a nonpreferred agent.

Quantity limits and dosing constraints

Aztreonam inhalation (Cayston) — quantity limit

Quantity limitOne 28‑day package per month.

IndicationAztreonam inhalation (Cayston) approved for cystic fibrosis patients with Pseudomonas aeruginosa when prescribed/managed by a CF treatment center specialist.

Authorization durationInitial approvals provided for 12 months; renewals annually with documentation of CF center visit within last 12 months and medication effectiveness.

Fidaxomicin — 10 days

Duration limitApprovals will be limited to 10 days.

IndicationFidaxomicin reserved for patients with C. difficile infection after inadequate response or contraindication to one or more courses of vancomycin.

Provider actionSubmit documentation of prior vancomycin treatment and rationale for fidaxomicin use with the PA request.

GATTEX dosing and initial approval duration

Typical dosing and limitGATTEX (teduglutide) doses up to 5 mg daily will be approved; initial approvals will be granted for three months.

ReauthorizationReauthorizations will be provided for up to a year with a documented reduction in parenteral nutrition volume requirements.

Indication criteriaReserved for adult patients with short bowel syndrome dependent on parenteral nutrition (e.g., ≥4 L daily) for at least one year and ≥3 days/week.

Site-of-care and billing rules

Note

ADAsuve self-administration site and equipment requirements

ADAsuve self‑administration is allowed only when on-site access to equipment and personnel trained for advanced airway management (including intubation and mechanical ventilation) is available; providers must ensure site capabilities before prescribing.

On-site access to advanced airway management equipment
Personnel trained for intubation and mechanical ventilation

Note

Aztreonam inhalation must be managed by CF specialists

Aztreonam inhalation (Cayston) must be prescribed and managed by specialists from a cystic fibrosis treatment center; providers should ensure specialist involvement when submitting a PA.

Billing Rule

ILET insulin pump billing through DME provider (home/site of care billing note)

ILET insulin pump is required to be billed through a DME provider as a medical claim; when billed through a DME vendor, prior authorization is not required — providers should coordinate billing with DME vendors.

Bill ILET through DME provider as a medical claim
No PA required if billed via DME vendor

Note

Pulmozyme managed by CF treatment center (site of care)

Pulmozyme therapy must be prescribed and managed by specialists from a cystic fibrosis treatment center; initial approvals are for 12 months and renewals require documentation of a specialist visit within the prior 12 months and effectiveness.

Prescribed and managed by CF treatment center specialist
Initial approval 12 months; annual renewal with specialist visit and effectiveness documentation

Billing Rule

Insulin pump billing/DME note (T:slim / Tandem examples)

Certain insulin pumps (examples: T:SLIM X2, TANDEM MOBI SYSTEM, TANDEM T:SLIM STARTER KIT) must be billed through a DME provider as a medical claim; prior authorization is not required when billed through a DME vendor.

Bill specified pumps through DME provider as medical claim
PA not required when billed via DME vendor

Background and scope

Background: This document lists nonpreferred medications subject to the Minnesota Health Care Programs (MHCP) Non‑Preferred Drug Prior Authorization Criteria. For many listed drugs, HealthPartners provides specific required clinical criteria via linked coverage PDFs; common reservation patterns include trial/failure of preferred agents, documented allergic reaction to equivalent generics, and restriction to FDA‑approved indications or specialist‑managed care where indicated.