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Nonpreferred drug prior authorization list and required clinical criteria

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Lists medications designated nonpreferred and subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; provides drug-specific required clinical criteria or links. Affects providers and pharmacists requesting coverage for HealthPartners members (MHCP/Minnesota-related criteria).

Policy Summary

PayerHealthPartners

PolicyNonpreferred drug prior authorization list and required clinical criteria

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 provide required drug-specific documentation or linked HealthPartners criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug entries in this excerpt

multipleentries reference external required-criteria documents

Minnesota DHSprior authorization criteria source

Coverage Criteria for Nonpreferred Drugs

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Many medications listed as nonpreferred require prior authorization under the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria. Providers must verify PA requirements and submit required documentation prior to dispensing.

Confirm whether the prescribed drug is listed as nonpreferred and subject to Minnesota DHS Non-Preferred Drug PA criteria.
Submit prior authorization requests with supporting clinical documentation per the referenced HealthPartners drug-specific or program PA criteria when applicable.
For long‑acting opioids and select specialty agents, include provider attestations (e.g., opioid management attestation for long‑acting opioids) and trial documentation (minimum 30 days short‑acting opioid trial where specified).
When a drug is reserved for allergy or failure of a preferred product, include documentation of allergy or trials of the preferred alternative(s) and reason for medical contraindication if applicable.
For drugs reserved to specific provider types or specialist-managed care (e.g., cystic fibrosis center, infectious disease, oncology), include documentation of specialist involvement or consultation.
When billing devices or pumps (e.g., certain insulin pumps/Minimed), follow DME billing rules — PA may not be required when billed through a DME vendor as a medical claim.

What Providers Must Do

Prior Authorization

MHCP Nonpreferred Drug Prior Authorization

Medications listed as nonpreferred under MHCP require prior authorization per the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; where an entry references a HealthPartners required-clinical-criteria PDF, providers must follow and document per that criteria.

Use the MHCP NP-PA criteria for authorization decisions unless the drug entry specifies alternate HealthPartners criteria.
Provide the documentation requested by the specific coverage-criteria PDF when a link is provided in the drug entry.

Prior Authorization

Long-acting opioid PA requirement

Long-acting opioids listed as nonpreferred require prior authorization that includes a provider attestation that opioid therapy is managed per standard opioid prescribing guidelines and evidence of an adequate prior short-acting opioid trial (minimum 30 days continuous use).

Provider must attest that therapy follows standard opioid prescribing guidelines.
Document prior adequate trial of a short‑acting opioid of at least 30 days continuous use.

Initial Therapy Constraints and Requirements

inv-144: Initial therapy constraints

Common initial coverage constraints in excerpt.

Initial constraints: Initial coverage often reserved for patients with documented allergic reaction to generic equivalent, or after inadequate response to preferred products, or when specific prescriber type is required (examples across entries).

See individual drug entries for specific initial constraints.

inv-145: Initial approval durations

Initial approval durations when specified.

Cayston initial approval: Initial approvals will be provided for twelve months; renewals annually with documentation of specialist visit and effectiveness.12 months initial

From Cayston entry.

Continuation and Renewal Criteria

inv-152: Renewal requirements

Continuation/renewal rules when specified in entries.

Dalfampridine ER renewal: After initial 6‑month approval, renewals require documented continued clinical improvement in ambulation; annual approvals thereafter for positive responders.annual renewals after 6 months

From DALFAMPRIDINE ER entry.

inv-153: Ophthalmic cystinosis agents

Continuation rules for cystinosis topical drops.

Cystadrops/Cystaran renewal: Initial approvals for three months; renewals require documentation of clinical treatment effect (slit lamp exam notes) and will be provided for up to one year.renewals up to 1 year

From CYSTADROPS/CYSTARAN entries.

Step Therapy and Prior Trial Requirements

Step therapy summary	Requirement
Documentation of prior trials or contraindications
Providers must document prior trial(s) of preferred product(s) or a medical contraindication; when claiming benefit over preferred alternatives, literature documentation of clinical benefit is required

Example	Requirement / note
Brivaracetam and other seizure agents
Reserved for patients with inadequate response to two or more preferred seizure medications; documentation of prior failures or contraindications required; some entries reference HealthPartners PDFs for detailed criteria

Example	Requirement / note
Multiple topical/systemic products (e.g., clobetasol, various branded agents)
Many drugs are reserved for use only after failure of preferred products or when there is a documented allergy/contraindication to the preferred generic or dosage form; documentation required

Example	Requirement / note
Dificid (fidaxomicin) and other agents
Approval requires trial and inadequate response to preferred alternatives (e.g., vancomycin for C. difficile); documented contraindication/allergy acceptable when specified

Instruction	Requirement
Document trials of preferred products as specified in individual drug entries
Individual drug lines specify which preferred alternatives must be tried and failed (examples include triptan/NSAID sequences and formulary dosage forms); follow per‑drug required clinical criteria

Instruction	Requirement / evidence
Document prior trial or contraindication per individual entry
Providers must supply clinical documentation showing prior trial(s) of preferred therapy or a documented contraindication; some entries require literature evidence of benefit over preferred alternatives

General rule	Requirement
Reserved-use after failure of preferred alternatives or with contraindication/allergy
Many listed products are reserved for patients who failed preferred alternatives or have contraindications/allergies to preferred products; documentation of failure or allergy required as specified

Coding, Dosage and Quantitative Requirements

Ambulation distance requirement for dalfampridine ER — inv-53: Ambulation distance requirement for dalfampridine ER — currently able to walk 25 feet

Ambulation requirementCurrently able to walk 25 feet

DiagnosisMultiple sclerosis

AttestationPhysician attestation that patient has difficulty walking required

Dalfampridine ER dosage limit — inv-54: Dalfampridine ER dosage limit — not more than FDA approved dosage of 10 mg twice daily

Dosage limitNot more than the FDA‑approved dosage: 10 mg twice daily

Initial approvalInitial approval for six months

Quantity Limits and Packaging

Cayston (aztreonam inhalation) — inv-170: Cayston (aztreonam inhalation) — one 28-day package

Quantity limitOne 28‑day package per month

IndicationApproved for cystic fibrosis patients with Pseudomonas aeruginosa in the lungs

Prescribing/managementMust be prescribed and managed by specialists from a cystic fibrosis treatment center

Site of Care and Billing Notes

Note

Self-administration of ADASUVE — site and justification requirements

Self-administration of ADASUVE requires justification for self-administration versus facility administration and on-site access to advanced airway management (including equipment and personnel trained for intubation and mechanical ventilation); include this justification and site capability documentation in requests.

Provide rationale for self-administration rather than facility administration.
Document site access to advanced airway management equipment and trained personnel.

Note

Cayston — specialist prescribing and renewal documentation

Cayston (aztreonam inhalation) must be prescribed and managed by specialists from a cystic fibrosis treatment center; initial approvals are for twelve months and renewals require documentation that the patient was seen within the last 12 months at the CF center and the medication is effective.

Prescriber must be a CF treatment center specialist or management must be by such a specialist.
Include documentation of specialist visit within prior 12 months and evidence of treatment effectiveness for renewals.

Definitions and Policy Terms

Nonpreferred — inv-130: Nonpreferred — A designation indicating the medication is subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria

Definition: NonpreferredA designation indicating the medication is subject to Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria and requires prior authorization for coverage

ImplicationCoverage requires meeting Minnesota DHS NP‑PA criteria or referenced HealthPartners criteria per drug

Common usageUsed throughout the document to flag products requiring PA or reserved use conditions

Reserved — inv-131: Reserved — Used in entries to indicate limited coverage for specific clinical circumstances such as allergy to generic, inadequate response to preferred alternatives

Definition: ReservedUsed to indicate limited coverage for specific clinical circumstances such as documented allergy to generic, inadequate response to preferred products, or specified prescriber types

Background and Scope

Background: this document is an administrative listing that marks many products as nonpreferred and points providers to the applicable required clinical criteria documents (often external HealthPartners PDFs or the Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria) that must be met for prior authorization and coverage determination.

Policy Summary

PayerHealthPartners

PolicyNonpreferred drug prior authorization list and required clinical criteria

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 provide required drug-specific documentation or linked HealthPartners criteria.

SourceLink

On This Page

Prior Authorization

Prior authorization requirement

Prior authorization must be obtained per the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria for medications designated nonpreferred; follow drug-level required clinical criteria where provided.

Submit documentation per the MHCP NP-PA criteria when requesting authorization.
If a drug entry lists required clinical criteria or a HealthPartners PDF, include that documentation with the PA.

Prior Authorization

Prior authorization required for nonpreferred drugs

These listed medications are nonpreferred and require prior authorization under the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; many entries include specific required-clinical criteria that must be supplied.

Ensure PA requests include the drug-specific documentation when a required-clinical-criteria link or statement appears in the entry.
Failure to provide required documentation per the referenced criteria may lead to denial.

Prior Authorization

Prior authorization required for nonpreferred medications

Many medications listed are nonpreferred and require prior authorization following the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; provide the documented rationale or link-based criteria as specified per drug.

If a drug entry directs to a HealthPartners coverage-criteria webpage or PDF, include the information requested by that document.
Include clinical justification (e.g., allergy to generic, failure of preferred products) when applicable.

Prior Authorization

Nonpreferred drugs require MHCP Non‑Preferred Drug PA

Medications listed as nonpreferred are subject to the Minnesota Department of Human Services Non‑Preferred Drug Prior Authorization Criteria; follow the MHCP NP‑PA criteria and any drug-specific documentation requirements when submitting a PA.

Adhere to MHCP NP‑PA standards for nonpreferred drugs.
Provide any additional drug-specific documentation noted in the entry (links or reserved statements).

Prior Authorization

Fentanyl patch PA requirement

For long‑acting fentanyl patch products, prior authorization requires provider attestation that opioid therapy is managed per standard opioid prescribing guidelines and documentation of a prior adequate trial (minimum 30 days continuous use) of a short‑acting opioid; MHCP NP‑PA criteria must also be met.

Include provider attestation per opioid-prescribing guidelines.
Document the prior short-acting opioid trial of at least 30 days.

Prior Authorization

Nonpreferred drugs require MHCP Non-Preferred Drug PA

These medications are listed nonpreferred and are subject to the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; where specific HealthPartners criteria are referenced, providers must follow and document per those criteria.

Submit PA with documentation required by either MHCP NP‑PA criteria or the HealthPartners required-clinical-criteria link provided in the entry.
Omit or incomplete documentation per the referenced criteria may result in denial.

Prior Authorization

Non-Preferred Drug Prior Authorization

Medications in this section are non-preferred and require prior authorization under the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; follow any linked HealthPartners clinical PA documents for drug-specific requirements.

Follow the MHCP NP‑PA criteria and any HealthPartners PDF linked in the drug entry.
Provide requested clinical information consistent with the linked criteria.

Prior Authorization

Opioid prior authorization requirement

Long-acting opioids listed as MHCP nonpreferred require prior authorization that includes a provider attestation of adherence to opioid prescribing guidelines and documentation of a prior adequate short‑acting opioid trial (minimum 30 days continuous use).

Provider attestation must state therapy is managed per standard opioid prescribing guidelines.
Document the short‑acting opioid trial of at least 30 days.

Billing Rule

Ilet insulin pump billing note

When billing the Ilet insulin pump, the device must be billed through a DME provider as a medical claim; prior authorization is not required when billed through a DME vendor.

Bill the Ilet insulin pump as a medical claim via a DME provider to avoid pharmacy PA.
If billed through DME vendor, prior authorization is not required.

Prior Authorization

Prior authorization required

These nonpreferred medications require prior authorization following the Minnesota DHS Non-Preferred Drug PA Criteria or the specific HealthPartners coverage criteria linked for certain drugs; include the required documentation when submitting a PA.

If a drug entry lists a specific HealthPartners coverage PDF, submit documentation per that document.
For MHCP nonpreferred drugs, include information required by the Minnesota DHS NP‑PA criteria.

Prior Authorization

MHCP Nonpreferred Drug PA requirement

Many listed medications are nonpreferred and require prior authorization per the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; some entries reference HealthPartners coverage PDFs or webpages that specify additional documentation requirements.

Provide drug-specific documentation when a HealthPartners PDF or webpage is referenced.
Ensure PA requests meet MHCP NP‑PA criteria when applicable.

Prior Authorization

L-glutamine PA duration

Initial and reauthorizations for L‑glutamine (as listed) are for 12 months; renewals require evidence the medication has provided positive impact (for sickle cell disease, a reduced frequency of painful crises).

Initial and reauthorization periods: 12 months.
Renewal requires documentation of positive clinical impact (e.g., fewer painful crises).

Prior Authorization

Nonpreferred drugs require PA

Medications labeled 'nonpreferred' require prior authorization per the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; include any specified drug-level required clinical documentation with the PA.

Attach drug-specific documentation or the MHCP NP‑PA attestation/link when required.
Incomplete submissions that do not meet referenced criteria risk denial.

Prior Authorization

Prior authorization required for MHCP non-preferred drugs

Many medications in the MHCP non-preferred list require prior authorization using the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria or the HealthPartners required clinical criteria linked for each drug.

Follow MHCP NP‑PA criteria and include drug-specific documentation when the entry references a HealthPartners required-clinical-criteria PDF.
Requests lacking the referenced documentation may be denied.

Prior Authorization

Nonpreferred Drug Prior Authorization

Listed medications are nonpreferred and subject to the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria; many entries include a URL to the specific required clinical criteria — include that documentation when requesting PA.

Include evidence specified by the linked HealthPartners criteria where a URL is provided.
For long-acting opioids, include provider attestation and prior short-acting opioid trial documentation as required.

Prior Authorization

Long-acting opioid MHCP PA requirement

For MHCP non-preferred long-acting opioid products, patients must meet the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria (link provided) and the PA must include a provider attestation that therapy is managed per opioid prescribing guidelines plus documentation of a prior adequate short‑acting opioid trial (minimum 30 days).

Include the MHCP NP‑PA link: https://mn.gov/dhs/assets/nonpreferred-drug-PA-criteria_tcm1053-379166.pdf when applicable.
Provider attestation and documentation of the short-acting opioid trial (≥30 days) are required.

Prior Authorization

Prior authorization required for nonpreferred drugs

Prior authorization is required for nonpreferred medications listed; some entries direct providers to specific HealthPartners coverage criteria web pages or PDFs for the detailed documentation required for PA.

When a drug entry provides a HealthPartners coverage-criteria link, submit documentation per that link.
If no drug-specific link is given, follow the MHCP NP‑PA criteria.

Prior Authorization

Nonpreferred drug prior authorization summary

Medications listed are nonpreferred and subject to the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization; many entries specify required clinical criteria or link to HealthPartners coverage criteria PDFs — include those materials when requesting authorization.

Provide the drug-specific required clinical criteria documentation when a PDF or link is referenced in the entry.
If the entry reserves a drug for allergy-to-generic or failure of preferred products, include supporting clinical documentation.

Step Therapy

Step therapy/fail-first noted

Multiple entries state that nonpreferred products are reserved for patients with an inadequate response to two or more preferred products or when there is a medical contraindication to preferred agents; providers must document prior trials or contraindications.

Document prior trials of preferred products (often two or more) and clinical rationale for switching to a nonpreferred product.
Provide relevant chart notes or literature evidence if the entry requires demonstration of clinical benefit over preferred alternatives.

Step Therapy

Reserve for failure of preferred products

Several drugs are reserved for patients who have had an inadequate response to two or more preferred products or have medical contraindications to preferred therapies; include documentation of prior failures or contraindications in the PA request.

List prior preferred agents tried, duration, and reason for discontinuation (e.g., lack of efficacy, adverse effects).
Attach supporting medical records demonstrating inadequate response or documented contraindication.

Step Therapy

Step therapy/reserved status

Multiple entries indicate medications are reserved for patients with inadequate response to preferred agents or require trials of preferred products; providers must document prior treatment attempts per the drug entry.

Provide dates and outcomes of prior therapy with preferred agents.
If reserved for specialist prescribing, include the specialist's documentation or consultation note.

Step Therapy

Step/therapeutic failure requirements

Many nonpreferred products are reserved for patients who have not responded to preferred therapies, have documented allergic reactions to generics, or have contraindications; PA submissions must include documentation of these conditions.

For allergy-to-generic exceptions, include documentation of the allergic reaction.
For inadequate response, provide clinical records showing treatment failure of preferred products.

Step Therapy

Step or trial requirements

Several drugs are reserved for use only after failure of one or more preferred products or when specified alternatives have been tried; providers must document prior trials as required by individual drug entries.

For drugs that require trials of multiple preferred alternatives, list each agent tried and the clinical outcome.
Provide any required specialty consult notes if the entry specifies specialist management.

Step Therapy

Reserve for inadequate response or contraindication

Some products are reserved for patients who failed preferred dosage forms or have medical contraindications; PA requests must include documentation of the failed dosage form or the contraindication.

Document prior use of the preferred dosage form and why it was ineffective or not tolerated.
Include evidence of contraindication (e.g., allergy, comorbidity) when claimed.

Step Therapy

Step/try preferred alternatives first

Multiple products are indicated as reserved for patients with inadequate response to a preferred dosage form or with medical contraindications to preferred products; providers must try preferred alternatives before requesting a nonpreferred product.

Document trials of preferred alternatives and rationale for escalation to nonpreferred product.
If reserved for a documented allergic reaction to generic, include the allergy documentation.

Step Therapy

Step/sequence requirements

Some entries require trials of two or more preferred products (or failure of specific dosage forms) before a nonpreferred product will be authorized; include explicit documentation of those trials in the PA submission.

List each preferred product tried, treatment duration, and reason for failure.
Attach supporting notes or test results demonstrating inadequate response where relevant.

Step Therapy

Failure of preferred alternatives

Many products are reserved for patients with inadequate response to preferred alternatives or medical contraindications; when two failed preferred agents are required, document both trials and reasons for failure.

Document the two (or specified number) of preferred agents tried and the clinical outcome.
Provide objective evidence (e.g., symptom scores, labs) when available to support inadequate response.

Step Therapy

Step therapy / inadequate response requirements

Multiple entries reserve nonpreferred products for patients who have had inadequate response to preferred products (often two or more) or who have contraindications; providers must document prior trials or contraindications per the entry.

Include clinical notes showing lack of efficacy or intolerance to preferred agents.
If literature documentation of benefit over preferred products is required, attach relevant references.

Step Therapy

Step therapy / failure to preferred products

Several products are reserved for patients who failed preferred products or dosage forms (examples include triptan or NSAID failures); ensure PA includes documentation of prior failures and clinical rationale.

List prior preferred agents tried (e.g., specific triptans, NSAIDs) and reasons for discontinuation.
Attach any specialty consult or evidence supporting the need for the nonpreferred product.

Step Therapy

Step requirements / trials

Several drugs are reserved until trials of preferred alternatives have failed or when there are contraindications to preferred options; providers must supply documentation of prior trials or contraindications with PA requests.

Provide dates, dosages, and responses for prior preferred therapies.
Include chart notes or lab results demonstrating contraindications where applicable.

Step Therapy

Required trials of preferred products

Several products require trials of two or more preferred products or documented contraindications before coverage; document prior trials, durations, and outcomes in the PA submission and include any required specialty documentation.

For products requiring two failed agents, include documentation for both agents.
Include culture/sensitivity, specialty consults, or other required evidence when specified by the entry.

Step Therapy

Step/step-up requirements (where specified)

Several drugs are reserved for patients who have tried and failed preferred products or dosage forms; providers should document prior trials and rationale (or contraindications) per the drug entry when requesting authorization.

Provide documentation of prior preferred therapy trials and outcomes.
When a specialist prescriber is required, include the specialist's notes or consultation.

Step Therapy

Step/failure therapy notes

Several nonpreferred drugs are reserved for patients with inadequate response to two or more preferred products or to preferred dosage forms; providers must provide documentation of prior failures or contraindications and may need to include literature evidence of benefit when requested.

Attach clinical records showing inadequate response to preferred alternatives.
If requested, provide literature supporting clinical benefit over preferred products.

Documentation Required

Required clinical documentation

For some products, documentation of inadequate response to preferred products, medical contraindications, or documented allergic reaction to generic equivalents is required; include the relevant clinical records when submitting a PA.

Provide chart notes, lab results, or specialist documentation supporting the clinical rationale.
If the entry references a HealthPartners required-clinical-criteria PDF, include the documentation specified by that PDF.

Documentation Required

Opioid attestation and opioid trial documentation

Long-acting opioids require a provider attestation that opioid therapy is being managed per standard opioid prescribing guidelines and documentation that the patient had an adequate trial (minimum 30 days continuous use) of a short-acting opioid; include this attestation and trial evidence with the PA.

Provider attestation must confirm management per opioid-prescribing guidelines.
Document prior short‑acting opioid use of at least 30 continuous days and the outcome.

Documentation Required

Reference-specific clinical criteria documentation

Some entries require providers to follow specific HealthPartners coverage-criteria PDFs or web pages; include the documentation specified by those external criteria when requesting prior authorization.

Locate and follow the HealthPartners required-clinical-criteria PDF linked in the drug entry.
Attach any forms or evidence the external criteria specify (e.g., lab values, specialist notes).

Documentation Required

Examples of required documentation

For some drugs with specific clinical criteria (for example, Cholbam and Cayston), required documentation includes items such as patient weight for dose verification (Cholbam) or specialist management and annual specialist visit documentation (Cayston) for renewals.

Cholbam: provide patient weight to verify dosing per entry requirements.
Cayston: include documentation that the patient is managed by a CF treatment center specialist and evidence of a specialist visit within the past 12 months for renewal.

Documentation Required

Dalfampridine documentation

Initial approval for dalfampridine ER is time-limited to six months and requires physician attestation of walking difficulty and documentation that the patient can walk 25 feet; renewals require documented improvement in ambulation.

Initial approval: physician attestation of walking difficulty and ability to walk 25 feet; prescribed by a neurologist and dose not exceeding 10 mg twice daily.
Renewal requires documentation of improved ambulation after six months.

Documentation Required

External criteria referenced

Some drug entries reference external HealthPartners coverage-criteria PDFs or web pages; providers must include the documentation specified by those external criteria when requesting prior authorization.

Find the linked HealthPartners coverage-criteria PDF in the drug entry and provide the requested documentation.
Examples include specific PDFs for DIACOMIT, DICHLORPHENAMIDE, DOXIL, and others.

Documentation Required

Required documentation for long‑acting opioids

Provider attestation that opioid therapy is managed per standard opioid prescribing guidelines and documentation of a prior adequate short‑acting opioid trial (minimum 30 days continuous use) are required where long‑acting opioid criteria specify these requirements; include both items with the PA.

Include a clear provider attestation statement referencing standard opioid prescribing guidelines.
Document the short‑acting opioid trial (dates, agent, dose, response) of at least 30 continuous days.

Documentation Required

GATTEX documentation and authorization durations

For GATTEX, prior authorization requires documentation that the patient is dependent on parenteral nutrition for at least one year, meets volume requirements (e.g., ≥4L daily), and other specified criteria; initial approvals are granted for three months with reauthorization up to one year as specified.

Document parenteral nutrition dependence ≥1 year and parenteral volume (e.g., ≥4L/day) where required.
Initial approval: 3 months; reauthorization criteria per GATTEX entry.

Documentation Required

Diabetes diagnosis documentation

For diabetes drugs reserved to FDA-approved indications (e.g., JANUMET, JANUVIA), providers must supply documentation confirming the diagnosis of type 2 diabetes, such as an ICD-10 code, medical records/chart notes, A1C or other lab results.

Include one of: ICD-10 diagnosis code for type 2 diabetes, medical records/chart notes documenting diagnosis, or A1C/lab results confirming diagnosis.
Attach the documentation with the PA request for diabetes-specific nonpreferred drugs.

Documentation Required

Specialty PA reference links

For certain specialty drugs, prior authorization documentation must follow the linked HealthPartners specialty PA criteria PDFs or web pages; include the specified documentation from those specialty criteria when requesting PA.

Follow the HealthPartners specialty PA PDF linked in the drug entry (examples: HUMATE-P, HYMPAVZI PEN, IDELVION, INFLECTRA, IMBRUVICA).
Attach any forms, labs, or specialist notes required by the specialty criteria.

Documentation Required

Required documentation

Providers must supply documentation confirming diagnosis or clinical rationale as specified per drug — examples include ICD-10 code, medical records/chart notes, A1C or other lab results, or documentation of allergic reaction or inadequate response to preferred products.

Include diagnosis confirmation (ICD-10, chart notes, labs) when required by the drug entry.
Document prior therapy failures, allergic reactions to generics, or specialist consultation as applicable.

Documentation Required

Opioid attestation and documentation

For long-acting opioids (including methadone formulations), provider attestation that therapy is managed per standard opioid prescribing guidelines is required, along with documentation of a prior adequate short‑acting opioid trial (minimum 30 days); MHCP NP‑PA criteria must also be met.

Provide a provider attestation statement confirming management per opioid-prescribing guidelines.
Document the prior short-acting opioid trial (≥30 days continuous use) and outcomes.

Documentation Required

Opioid attestation and MN DHS criteria

Long-acting opioids require provider attestation that therapy is managed per opioid prescribing guidelines and documentation of an inadequate response to a recent adequate short‑acting opioid trial (minimum 30 days continuous use); MHCP nonpreferred products must meet Minnesota DHS NP‑PA criteria (link provided).

Attach provider attestation and documentation of the short-acting opioid trial (dates, agent, response).
Include MHCP NP‑PA documentation where required by the drug entry.

Documentation Required

Documentation requirement

Providers must supply documentation as specified by the referenced required clinical criteria PDFs or HealthPartners coverage webpages when requesting prior authorization for nonpreferred products; attach the materials referenced in the drug entry.

Locate the specific required-clinical-criteria PDF referenced in the drug entry and include the documentation requested.
Incomplete documentation per the referenced criteria may result in denial.

Documentation Required

OZEMPIC documentation

For OZEMPIC, documentation to confirm a diagnosis of type 2 diabetes must be included with the PA request — acceptable evidence includes an ICD-10 code, medical records/chart notes, or A1C/other lab results.

Include one of: ICD-10 diagnosis code for type 2 diabetes, medical records/chart notes, or A1C/other lab results confirming diagnosis.
Attach these materials to the PA submission for OZEMPIC.

Documentation Required

Long-acting opioid attestation

For long-acting opioids such as OXYCODONE HCL ER, OXYCONTIN, and OXYMORPHONE HCL ER, provider attestation that therapy is managed per standard opioid prescribing guidelines and documentation of a prior adequate short‑acting opioid trial (minimum 30 days continuous use) are required with the PA.

Include provider attestation referencing opioid-prescribing guidelines.
Document the prior short-acting opioid trial (≥30 days) and clinical response.

Documentation Required

PULMOZYME documentation and renewal

For PULMOZYME, initial approvals are for twelve months; renewals require annual documentation that the patient was seen within the last 12 months at a cystic fibrosis treatment center and that the medication is effective.

Initial authorization: 12 months.
Renewal requires documentation of specialist visit within last 12 months and evidence medication is effective.

Documentation Required

Documentation per referenced criteria

Provide documentation per referenced HealthPartners coverage criteria PDFs or webpages when indicated (for example, specialist management notes for Pulmozyme and culture/sensitivity for Nuzyra); include the specified documents with the PA request.

Attach specialist notes, culture/sensitivity results, or other materials required by the referenced HealthPartners criteria.
Follow the exact documentation list in the linked coverage-criteria PDF for each drug.

Documentation Required

Secuado documentation requirement

For Secuado, include chart documentation that the patient was previously stable on asenapine sublingual tablets and experienced mouth sores necessitating the change in therapy; the agent must be prescribed by or in consultation with a behavioral health provider.

Include chart notes documenting prior stability on asenapine sublingual tablets and the adverse event (mouth sores).
Ensure the PA indicates prescribing by or consultation with a behavioral health provider.

Denial Risk

Nonpreferred designation triggers PA

Medication designated as nonpreferred and subject to the Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria will require PA; failing to request or obtain PA per those criteria may trigger denial.

Check the drug entry: if marked nonpreferred, submit PA per MHCP NP‑PA criteria.
Absence of required PA documentation in the submission can result in denial.

Denial Risk

MHCP Nonpreferred Drug Prior Authorization denial risk

Medications designated nonpreferred may be denied if the Minnesota DHS Non-Preferred Drug Prior Authorization Criteria are not met; ensure PA submissions contain the documentation required by the state criteria or the specific HealthPartners drug criteria.

Provide all documentation required by the MHCP NP‑PA criteria or the drug-specific HealthPartners PDF to avoid denial.
Denials commonly occur when required attestation, prior-trial documentation, or specialist documentation is missing.

Denial Risk

Nonpreferred drugs require MHCP Non-Preferred Drug PA (denial risk)

Medications listed as nonpreferred are subject to MHCP NP‑PA Criteria; failure to meet those criteria will trigger prior authorization denial or noncoverage — long‑acting opioids additionally require provider attestation and documentation of a prior short‑acting opioid trial.

For long-acting opioids, include the provider attestation and documentation of the prior short-acting opioid trial (≥30 days) to mitigate denial risk.
When a drug entry lists required clinical criteria, include that documentation to reduce likelihood of denial.

Denial Risk

Nonpreferred status and PA risk

Drugs listed as nonpreferred are subject to Minnesota DHS NP‑PA Criteria; failure to provide the required MHCP PA documentation (e.g., allergy-to-generic evidence, prior trials, provider attestations) may trigger denial of the PA request.

Include allergy documentation when the drug entry reserves product for allergy-to-generic.
Provide prior-trial documentation when step therapy or failure-of-preferred criteria are listed.

Denial Risk

Nonpreferred drug PA requirement (denial risk)

Use of listed nonpreferred medications without meeting Minnesota DHS Non-Preferred Drug Prior Authorization Criteria may trigger prior authorization denial; include all required evidence per the drug entry.

Verify the PA submission meets MHCP NP‑PA criteria and any drug-specific required-clinical-criteria.
Incomplete or missing documentation consistent with the entry is a common denial trigger.

Denial Risk

Denial triggers

Failure to meet MHCP Non‑Preferred Drug Prior Authorization Criteria can trigger denial; for long‑acting opioids this includes the requirement for provider attestation and documentation of a prior short‑acting opioid trial (minimum 30 days continuous use).

Attach provider attestation and documentation of a ≥30‑day short-acting opioid trial when requesting PA for long‑acting opioids.
Ensure other MHCP NP‑PA documentation requested by the drug entry is included to avoid denial.

Denial Risk

MHCP Non-Preferred PA criteria requirement

For MHCP non-preferred products (including long-acting opioids), patients must meet Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; failing to satisfy those criteria may result in denial.

Provide the documentation required by the MHCP NP‑PA criteria and any drug-specific criteria linked in the entry.
Denial may follow when required evidence (e.g., attestations, prior-trial documentation) is absent.

Denial Risk

Opioid attestation required

Long-acting opioids (nonpreferred) require a provider attestation that therapy is managed per standard opioid prescribing guidelines; lack of this attestation and supporting documentation of prior short‑acting opioid trial (minimum 30 days) can cause PA denial.

Include the required provider attestation statement in the PA.
Document prior short-acting opioid trial of at least 30 days to support medical necessity for long-acting opioid therapy.

Denial Risk

HYSINGLA ER restrictions

For HYSINGLA ER 60 mg tablet (and similar multi-source products), authorization may be reserved for patients with a documented allergic reaction to the equivalent generic; long-acting opioid attestation is required for certain formulations — failure to provide these can lead to denial.

If claiming allergy-to-generic, include documentation of the allergic reaction.
For long-acting opioid formulations, include the provider attestation and prior trial documentation as specified.

Denial Risk

Nonpreferred drugs require MHCP PA (denial risk)

Medication listed as nonpreferred and subject to Minnesota DHS NP‑PA Criteria will require prior authorization; lacking the required MHCP PA documentation may trigger denial of coverage.

Include all documentation called for in the drug entry (e.g., diagnosis confirmation, prior-trial documentation, attestations).
Denials commonly result when documentation specified by the MHCP NP‑PA criteria is not provided.

Denial Risk

Denial triggers for nonpreferred drugs

Failure to meet Minnesota DHS Non-Preferred Drug Prior Authorization Criteria or to supply required drug-specific clinical documentation may trigger denial for nonpreferred drugs.

Review the drug entry for required documentation (e.g., diagnostic evidence, prior trials, specialty consults) before submitting PA.
Omit or insufficient documentation per entry requirements increases denial risk.

Denial Risk

Non-preferred drug PA requirement (denial risk)

Drugs listed as nonpreferred are subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; failing to meet those criteria or to provide requested documentation may lead to denial of the PA.

Ensure PA submissions include the evidence requested by MHCP NP‑PA criteria or the drug-specific required-clinical-criteria.
Provide clear documentation of prior trials, allergies, or specialist input where the entry requires it.

Denial Risk

Denial risk for MHCP non-preferred drugs

Failure to provide required Minnesota DHS Non-Preferred Drug Prior Authorization Criteria documentation (for example, provider attestation for long-acting opioids and evidence of a prior short‑acting opioid trial) may trigger denial of requests for MHCP non-preferred drugs.

Include provider attestations and prior-trial documentation for long-acting opioids as specified.
Attach any drug-specific documentation required by linked HealthPartners criteria to avoid denials.

Denial Risk

Nonpreferred drugs require PA (denial risk)

Drugs listed as 'nonpreferred' and subject to the Minnesota DHS NP‑PA Criteria require prior authorization; omission of required documentation per the entry or the MHCP NP‑PA criteria may result in denial.

Review each drug entry for specific documentation requirements (e.g., allergy evidence, prior-trial records, specialty consults).
Submit complete PA documentation per MHCP NP‑PA criteria or linked HealthPartners PDFs.

Denial Risk

Nonpreferred drug PA requirement (denial risk)

Coverage requires prior authorization when a medication is nonpreferred and subject to Minnesota DHS Non-Preferred Drug Prior Authorization Criteria; failure to include required clinical criteria or referenced link-based documentation may trigger denial.

If the entry references a HealthPartners coverage PDF, include the specified documentation from that link.
Incomplete submissions lacking required evidence are at risk for denial.

Denial Risk

Nonpreferred drug prior authorization requirement (denial risk)

Use of listed nonpreferred medications is subject to Minnesota DHS Non-Preferred Drug Prior Authorization criteria; lacking the required criteria or documentation may trigger denial — include all requested evidence per the drug entry.

Confirm the drug entry's required clinical criteria and include them with the PA.
Document prior failures, allergies, or specialist management as required to reduce denial risk.

Cholbam initial authorization: Initial authorization provided for 6 months; reauthorization contingent on improved liver function and annually thereafter if effective.6 months initial

inv-146: Initial therapy requirements

Initial approval conditions when specified.

Dalfampridine ER initial approval: Initial approval for dalfampridine ER is for six months and requires: diagnosis of multiple sclerosis; ability to walk 25 feet; physician attestation of walking difficulty; neurologist prescribing; and dosage not to exceed FDA‑approved 10 mg twice daily.10 mg twice daily max

From DALFAMPRIDINE ER entry.

Cystadrops/Cystaran initial approval: Initial approvals for cystinosis topical drops provided for three months when prescribed by a specialist with diagnosis of cystinosis; renewals require slit lamp exam documentation and clinical effect.3 months initial

From CYSTADROPS/CYSTARAN entries.

inv-147: Initial authorization examples

Where provided, initial authorization conditions include:

DIFICID (fidaxomicin): Reserved for patients with C. difficile infection and inadequate response or contraindication to vancomycin; approvals limited to 10 days.10 days

From DIFICID/FIDAXOMICIN entries.

ENDARI initial authorization: Diagnosis of sickle cell disease; patient >=5 years; ≥2 painful crises in prior 12 months despite continuous hydroxyurea unless contraindicated; prescribed within FDA dose; meet MN DHS NP‑PA criteria; initial/reauthorizations for 12 months.>=2 crises in 12 months

From ENDARI entry.

inv-148: GATTEX initial therapy

GATTEX initial authorization

GATTEX initial criteria: Adult patient with short bowel syndrome dependent on parenteral nutrition for at least one year, dependent on parenteral support ≥3 days/week and significant volume (e.g., ≥4L/day); initial approval 3 months.>=1 year; >=3 days/week; >=4L/day

From GATTEX entry.

inv-149: Initial therapy rules

Initial authorization conditions for certain agents:

LANREOTIDE initial approval: Somatuline Depot reserved for patients for whom surgery is not an option or not curative and who have failed one somatostatin analogue; initial approvals for six months with annual renewals for responders.6 months initial

From SOMATULINE/Signifor patterns.

KYGEVVI initial approval: Reserved for use in FDA‑approved indications and dosing for patients meeting trial inclusion/exclusion and guideline alignment who have tried/failed alternatives or have contraindications; approvals for 6 months where specified.6 months initial

From KYGEVVI entry.

inv-150: L-Glutamine initial therapy

L‑Glutamine initial authorization requirements.

Initial L-glutamine: Patient >=5 years; two or more painful crises in prior 12 months despite continuous hydroxyurea unless contraindicated; prescribed within FDA‑approved dose; meet MN DHS NP‑PA criteria; initial and reauthorizations for 12 months with annual renewals contingent on positive impact.>=5 years; >=2 crises in 12 months

From L‑GLUTAMINE entry.

inv-151: Initial therapy durations where specified

Initial approval examples where specified.

Pulmozyme initial approval: Initial approvals will be provided for twelve months when prescribed and managed by a cystic fibrosis treatment center; renewals annually with documentation of specialist visit and effectiveness.12 months initial

From PULMOZYME entry.

inv-154: Continuation therapy

Continuation/renewal rules found for some agents:

Renewal for responders: Initial time‑limited approvals (e.g., 3–6 months) are followed by annual renewals for responders with documented clinical improvement.annual

Examples include somatostatin analogues and other specialty agents.

Rule	Requirement
Trial and failure of preferred alternatives or documented contraindication/allergy
Coverage is conditioned on documented trials and inadequate response to specified preferred alternatives, or documentation of contraindication/allergy; follow per‑drug wording

Policy	Requirement
Preferred-alternative trial required before nonpreferred coverage
For many nonpreferred products, a trial of preferred alternatives is required prior to authorizing the nonpreferred product; number of required failures varies by drug and is specified in each entry

Instruction	Documentation needed
Document prior trials and rationale or documented contraindication/allergy
Providers must include clinical rationale or documentation of contraindication/allergy when prior trials of preferred products are not feasible or failed

Policy	Requirement
Some drugs reserved until trials of preferred alternatives have failed
Certain entries explicitly require failure of two preferred products or failure of preferred topical/dosage forms prior to approval of the nonpreferred product; document failures per entry

Opioid-specific requirement	Documentation
Provider attestation of opioid-prescribing per guidelines
Long‑acting opioids require a provider attestation that opioid therapy is managed per standard opioid prescribing guidelines and documentation of a prior adequate short‑acting opioid trial (minimum 30 days continuous use); MHCP nonpreferred PA criteria must also be met

Example	Requirement / note
Brand products reserved for allergy or failure of generics (examples across list)
Some drugs are reserved only after documented failure of preferred alternatives or documented allergy to generic equivalents; documentation and, where specified, literature support required

Policy	Requirement
Trial and failure of preferred products or contraindication documented before nonpreferred coverage
Per‑drug entries require documentation that preferred products were tried and failed (often one or two products) or that a contraindication/allergy exists; follow the exact per‑drug criteria for number and type of trials required

Reserved-use statement	Requirement / evidence
Reserved for patients with inadequate response to preferred alternatives or with contraindications
For some products, authorization is reserved for patients who have inadequate response to preferred alternatives; documentation in the medical literature of clinical benefits over preferred alternatives may be required when claimed

Renewals require documented improvement in ambulation

Parenteral nutrition volume — inv-55: Parenteral nutrition volume — >= 4L daily

Parenteral nutrition volume threshold>= 4 L daily

Duration requirementDependent on parenteral nutrition for at least one year

Reauthorization metricReauthorization contingent on documented reduction in parenteral nutrition volume

LDL threshold for Nexletol/Nexlizet — inv-56: LDL threshold for Nexletol/Nexlizet — >= 70 mg/dL

LDL threshold>= 70 mg/dL

Therapy contextWhen inadequate response to high‑intensity statins or statin contraindication and inadequate response to ezetimibe (or ezetimibe allergy)

Authorization termApprovals are given for one year; reauthorization based on LDL reduction per provider attestation

Opioid trial duration — inv-57: Opioid trial duration — minimum of 30 days of continuous use

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

DocumentationProvider attestation that opioid therapy is managed per standard opioid prescribing guidelines required

ApplicabilityApplies to long‑acting opioids listed as MHCP nonpreferred (must also meet MN DHS NP‑PA criteria)

Initial approval (GATTEX) — inv-140: Initial approval (GATTEX) — Initial approvals will be granted for three months for adult patients meeting GATTEX criteria

Initial approval length (GATTEX)Initial approvals will be granted for three months for adult patients meeting GATTEX criteria

Documentation requiredDocumentation of dependence on parenteral nutrition for at least one year and parenteral volume (e.g., >=4L daily)

ReauthorizationReauthorization may be granted up to one year with documented reduction in parenteral nutrition volume

Documentation to confirm diagnosis — inv-141: Documentation to confirm diagnosis — Evidence such as ICD-10 code, medical records, chart notes, A1C or other lab results to support diagnosis

Acceptable documentationEvidence such as ICD‑10 code, medical records/chart notes, A1C or other lab results to support diagnosis

Use casesRequired where drug is reserved for FDA‑approved indications (example: diabetes medications)

Other supporting docsProvider chart notes or specialist documentation may be required per individual drug criteria

Typical examplesAllergy to generic, failure of preferred agents, pediatric prescribing restrictions, FDA‑approved indication only

Nonpreferred medication (MHCP) — inv-132: Nonpreferred medication (MHCP) — A medication designated as nonpreferred under Minnesota DHS subject to NP-PA Criteria

Definition: MHCP nonpreferred medicationA medication designated nonpreferred under Minnesota DHS and subject to the state's Non‑Preferred Drug Prior Authorization Criteria

Coverage consequenceMust meet Minnesota DHS NP‑PA criteria; failure to do so may trigger denial

Provider attestation (opioid) — inv-133: Provider attestation (opioid) — A written attestation that opioid therapy is managed per standard opioid prescribing guidelines

Provider attestation (opioid)A written attestation that opioid therapy is managed per standard opioid prescribing guidelines and that the patient had an adequate trial (minimum 30 days continuous use) of a short‑acting opioid

When requiredRequired for long‑acting opioids and some fentanyl patch products listed as nonpreferred

Nonpreferred medication — inv-134: Nonpreferred medication — A medication designated as nonpreferred on the HealthPartners formulary and subject to MHCP NP-PA Criteria

Definition: Nonpreferred (HealthPartners)A medication designated as nonpreferred on the HealthPartners formulary and subject to Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria

Policy noteEntries may include 'Y' flag or reserved language indicating additional restrictions

Nonpreferred — inv-135: Nonpreferred — Medication status indicating it is subject to MN DHS NP-PA Criteria

Nonpreferred status implicationMedication status indicating it is subject to Minnesota DHS Non‑Preferred Drug Prior Authorization Criteria and typically requires PA for coverage

Common reserved reasonsDocumented allergy to generic, inadequate response to preferred alternatives, or specific prescriber requirements

Reserved — inv-136: Reserved — Some products flagged 'Y' or described as reserved for specific patient groups

Definition: Reserved (flags)Some products flagged 'Y' or described as reserved for specific patient groups (e.g., children ≤6, specialist prescribing, documented allergy to generic)

Effect on PAFlagged/reserved products often carry more restrictive PA criteria or documentation requirements

Nonpreferred Drug Prior Authorization Criteria — inv-137: Nonpreferred Drug Prior Authorization Criteria — Minnesota DHS criteria referenced

Definition: Non‑Preferred Drug PA Criteria (MN DHS)Minnesota Department of Human Services criteria that determine when nonpreferred medications will be authorized

Reference linkMN DHS NP‑PA criteria referenced in document: https://mn.gov/dhs/assets/nonpreferred-drug-PA-criteria_tcm1053-379166.pdf

Provider attestation — inv-138: Provider attestation (opioid) — A documented statement by the prescriber attesting that opioid therapy is managed per guidelines

Definition: Provider attestationA documented statement by the prescriber attesting that opioid therapy is being managed per standard opioid prescribing guidelines (often required for long‑acting opioids)

Associated requirementOften paired with documentation of prior adequate short‑acting opioid trial (minimum 30 days)

Reserved use — inv-139: Reserved use — Policy designation reserving a nonpreferred medication for specific patient circumstances

Definition: Reserved usePhrase used to indicate the restricted circumstance under which a nonpreferred medication may be authorized (e.g., allergy to generic, inadequate response to preferred product, specialist prescribing)

Typical examplesAllergy to generic equivalent, failure of preferred products, FDA‑approved indications only, specialist management

Initial approval (GATTEX) — inv-140: Initial approval (GATTEX) — Initial approvals will be for three months for adults meeting criteria

GATTEX initial approvalInitial approvals will be granted for three months for adult patients meeting GATTEX criteria

Conditions referencedApplies where GATTEX entry specifies initial 3‑month approval prior to longer reauthorization

Documentation to confirm diagnosis — inv-141: Documentation to confirm diagnosis — Evidence such as ICD-10, labs, chart notes to support diagnosis

Documentation to confirm diagnosisEvidence such as ICD‑10 code, medical records, chart notes, A1C or other lab results to support diagnosis

Drugs exampleUsed for diabetes drug entries (e.g., JANUVIA, JENTADUETO) and OZEMPIC documentation requirements

Reserved for patients with documented allergic reaction — inv-142: Reserved for patients with documented allergic reaction — Coverage reserved when patient has documented allergic reaction to equivalent generic

Reserved for allergy to genericCoverage reserved when patient has documented allergic reaction to the equivalent generic product

OccurrenceFrequently used across multiple branded products in the document as a reason to authorize a nonpreferred brand

Reserved for patients — inv-143: Reserved for patients — Phrase used to indicate restricted circumstance under which a nonpreferred medication may be authorized

Phrase meaning'Reserved for patients' indicates restricted circumstance under which a nonpreferred medication may be authorized (e.g., allergy to generic, failed preferred therapy)

Usage guidanceRefer to individual drug lines for exact reserved criteria and required documentation