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Drug Specific Prior Authorization

Drugs listed on this page require prior authorization from Health Partners (Medicaid) and KidzPartners (CHIP). 

Please note that there are different prior authorization forms for Health Partners Medicare.  To access those forms visit our Health Partners Medicare site. Forms are also sent to different fax numbers. 

If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help assure that we have the information necessary to make a decision about your request.

 

2020 Non-PDL Prior Authorizations:

Apokyn

H.P. Acthar Gel

Megace ES

Non-Preferred Drug (non PDL)

Pulmozyme

Strensiq

Synagis

Targretin 1% Gel

 

2020 PDL Prior Authorizations:

Acne Agents – Oral

Acne Agents – Topical

Alzheimer’s Agents

Analgesics – Long-Acting Opioids

Analgesics – Non-Opioid Barbituate Combinations

Analgesics – Opioid Short-Acting

Androgenic Agents

Angiotensin Modulators

Angiotensin Modulators – Combinations

Antianginal Agents

Antibiotics – GI and Related Agents

Antibiotics - Inhaled

Antibiotics – Topical

Anticoagulants

Anticonvulsants

Antidepressants

Antidepressants – SSRIs

Antiemetics – Antivertigo Agents

Antifungals – Oral

Antifungals – Topical

Antihemophilia Agents

Antihistamines – Minimally Sedating

Antihypertensives – Sympatholytic

Antihyperuricemics

Antimalarials

Antimigraine Agents - Other

Antimigraine Agents - Triptans

Antiparasitics – Topical

Antiparkinson’s Agents

Antipsoriatics – Oral

Antipsoriatics – Topical

Antipsychotics

Antivirals – CMV

Antivirals – Herpes

Antivirals – Influenza

Anxiolytics

Apokyn

Beta Blockers

Bile Salts

Bladder Relaxant Preparations

Blood Glucose Meters and Test Strips

Bone Density Regulators

Botulinum Toxins

BPH Treatments

Bronchodilators – Beta Agonist

Calcium Channel  Blockers

Cephalosporins

Colony Stimulating Factors

Contraceptives – Oral

Contraceptives – Other

Contraceptives

COPD Agents

Cytokine and CAM Antagonists

Dupixent

Enzyme Replacements – Gaucher Disease

Epinephrine – Self-Injected

Erythropoiesis Stimulating Proteins

Estrogens

Fluoroquinolones – Oral

GI Motility Agents – Chronic

Glucocorticoids – Inhaled

Glucocorticoids - Oral

Growth Hormones

H. Pylori Treatments

Hepatitis B Agents

Hepatitis C Agents

Hereditary Angioedema Agents

Histamine 2 Receptor Blockers

HIV-AIDS Antiretrovirals

Hypoglycemics – Alpha Glucosidase Inhibitors

Hypoglycemics – Incretin Mimetics

Hypoglycemics – Insulins and Related Agents

Hypoglycemics – Meglitinides

Hypoglycemics – Metformins

Hypoglycemics – SGLT-2 Inhibitors

Hypoglycemis – Sulfonylureas

Hypoglycemis – TZDs

Idiopathic Pulmonary Fibrosis Agents

Immunomodulators – Atopic Dermatitis

Immunomodulators – Topical

Immunosuppressives – Oral

Intra-Articular Hyaluronates

Intranasal Rhinitis Agents

Iron – Oral

Iron – Parenteral

Iron – Chelating Agents

Kuvan

Leukotriene Modifiers

Lipotropics – Other

Lipotropics – Statins

Local Topical Anesthetics

Macrolides

Macular Degeneration Agents

Methotrexate

Monoclonal Antibodies

Multiple Sclerosis Agents

Neuropathic Pain Agents

NSAIDs

Nuedexta

Oncology Agents – Breast Cancer

Oncology Agents – Oral

Ophthmalics - Allergic Conjunctivitis

Ophthmalics – Antibiotic Steriod

Ophthmalics – Antibiotics

Ophthmalics – Anti-inflammatories

Ophthmalics – Glaucoma

Ophthmalics – Immunomodulators

Opioid Dependence Treatment

Opioid Overdose Agents

Otic Antibiotics

PAH Agents

Palynziq

Pancreatic Enzymes

Penicillins

Phosphate Binders

Pituitary Suppressive Agents - LHRH

Platelet Aggregation Inhibitors

Potassium Removing Agents

Prenatal Vitamins

Progestational Agents

Proton Pump Inhibitors

Pulmozyme

Sedative Hypnotics

Skeletal Muscle Relaxants

Smoking Cessation Agents

Steroids – Topical

Stimulants and Related Agents

Tetracyclines 

Thalidomide and derivatives

Thrombopoietics

Thyroid Hormones

Tolvaptan (Jynarque & Samsca)

Tysabri

Ulcerative Colitis Agents

Urea Cycle Disorder Agents

Urinary Anti-Infectives

Vaginal Anti-Infectives

Vitamin D Analogs

VMAT2

Xyrem

Zyvox