HealthPartners Coverage Criteria
Latest HealthPartners coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-012026 Medicare Part D Prior Authorization Requirements — Specialty & Part D DrugsDefines prior authorization, coverage criteria, exclusions, prescriber and duration rules for Medicare Part D prescription drugs on the HealthPartners formulary; affects prescribers and pharmacists submitting Part D PA requests for affected products.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-012026 Medicare Part D Prior Authorization Requirements — Part D formulary coverage criteriaLists prior authorization requirements, criteria, and coverage details for multiple prescription drugs on the HealthPartners 2026 Medicare Part D formulary; applies to Part D benefits and prescribers/providers submitting PA requests.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-012026 Medicare Part D Prior Authorization Requirements — Part D prior authorization and coverage criteriaRules governing prior authorization, coverage criteria, exclusions, and required documentation for multiple Part D drugs on the HealthPartners Part D formulary effective March 1, 2026; applies to Medicare Part D claims under HealthPartners.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01HSA Plus 2026 Formulary (Drug List) — Pharmacy Coverage CriteriaLists medicines covered by the HSA Plus pharmacy benefit, defines tiers and program flags (PA, ST, QL, AL, ONC, OP, ACA, TD, S), and provides drug-specific tier and utilization controls relevant to HealthPartners members and providers.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-012026 Formulary (Drug List) — Pharmacy Coverage CriteriaGoverns the HealthPartners pharmacy drug list (formulary) effective January 1, 2026; informs members and providers about covered medicines, tiers, specialty designations, limits, and prior authorization/step-therapy programs.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01HealthPartners 2026 Formulary — Coverage Criteria (Pharmacy & Specialty Drugs)This document is the HealthPartners drug list (formulary) effective January 1, 2026, describing covered medicines, tiers, specialty drug rules, and common formulary restrictions for HealthPartners members and providers.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyACA Preventive Medications List — Coverage CriteriaDefines which medications HealthPartners covers as Affordable Care Act (ACA) preventive medications at no cost for eligible commercial plan members and summarizes limits and coverage rules.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyACA Preventive Medications — Coverage CriteriaDefines which medications HealthPartners classifies as ACA preventive medications for Commercial Plans and outlines coverage expectations (e.g., no cost-sharing) and applicability to members when filled at in-network pharmacies. Affects providers prescribing and dispensing preventive medications to HealthPartners commercial members.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyACA Preventive Medications — Coverage Criteria (Commercial Plans)Defines which medications HealthPartners classifies as ACA preventive medications for Commercial Plans, notes coverage may be subject to plan rules (prior authorization, step therapy, quantity limits), and applies to prescriptions filled at in-network pharmacies.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyCommercial Formulary Prior Authorization and Step Therapy Coverage CriteriaDefines HealthPartners commercial pharmacy prior authorization (PA) and step therapy (ST) requirements for medications on the 2026 formulary; applies to prescribers and members under the HealthPartners commercial pharmacy benefit.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyCommercial Formulary Prior Authorization and Step Therapy Coverage Criteria — Pharmacy & Specialty DrugsThis document lists HealthPartners' commercial drug-list prior authorization (PA) and step therapy (ST) criteria for pharmacy and specialty drugs, explaining when PA/ST is required and linking to specific drug criteria. It affects providers and members covered under HealthPartners commercial pharmacy benefits.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEnhanced HSA Preventive Drug List (Coverage Criteria)Defines which medications are covered as preventive drugs for members in employer-offered HSA-eligible high deductible health plans, describing that listed drugs may be purchased with a copay rather than applied to the deductible; applies to HealthPartners members with such plans.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyEnhanced HSA Preventive Drug List — Coverage CriteriaDefines medications included on HealthPartners' Enhanced HSA Preventive Drug List for members in HSA-eligible high deductible health plans; describes how the list is presented and notes that coverage rules and plan documents govern actual benefits.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyExcluded Drug List — Coverage CriteriaLists specific drugs and drug formulations that are excluded from coverage under HealthPartners benefits and suggests alternative therapies; intended for providers and members to determine coverage eligibility.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyFormulary prior authorization and step therapy coverage criteria (Commercial)HealthPartners commercial formulary guidance describing prior authorization (PA) and step therapy (ST) rules for pharmacy drugs; applies to providers and members under the commercial pharmacy benefits.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyFormulary prior authorization and step therapy coverage criteria (pharmacy)HealthPartners Commercial 2026 formulary document describing prior authorization and step therapy requirements for prescription drugs under the pharmacy benefit; applies to providers prescribing and pharmacies dispensing medications for affected members.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyMedicare Part D Medication Transition (One-time Temporary Supply) Coverage CriteriaRules for providing one-time, temporary transition supplies of Part D medications to HealthPartners Medicare Part D enrollees, including new enrollees, those switching plans, and residents of long-term care facilities. Applies to coverage and dispensing practices during the first 90 days of enrollment or contract year and to continuing enrollees affected by negative formulary changes.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyNon-Preferred Drug Prior Authorization List (partial)List of medications designated as nonpreferred and subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization criteria; indicates reserved uses or required clinical criteria links for specific products. Affects providers prescribing these medications for HealthPartners members.All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyNonpreferred Drug Prior Authorization List (MHCP Non‑Preferred Drug PA Criteria)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).All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyNonpreferred drug prior authorization list and required clinical criteriaLists 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).All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyNonpreferred drugs list and required clinical criteria (partial)Lists nonpreferred medications subject to Minnesota Department of Human Services Non-Preferred Drug Prior Authorization Criteria and points to required clinical criteria or specific HealthPartners coverage criteria documents; affects prescribers and pharmacists for HealthPartners members (MHCP/Minnesota).All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyACA preventive medications list — Coverage criteriaAll HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyCommercial Formulary Prior Authorization and Step Therapy Coverage CriteriaAll HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyCommercial Formulary Prior Authorization and Step Therapy Coverage Criteria (partial)All HealthPartners updates
- Coverage CriteriaClinical/Medical PolicyNonpreferred Drug Prior Authorization / Coverage Criteria (MHCP/Minnesota DHS referenced)All HealthPartners updates
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Tool Description
Search HealthPartners coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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