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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.

Abilify Maintena - Initial 

Abilify Maintena - Renewal

Actemra- Initial

Actemra- Renewal

Adcirca - Initial

Adcirca - Renewal

Afinitor

Ampyra - Initial

Ampyra - Renewal

Androgel - Initial

Androgel - Renewal

Atypical Antipsychotics Under 18 - Initial

Atypical Antipsychotics Under 18 - Renewal

Aubagio

Avonex

Benzodiazepine w/ Buprenorphine Initial

Benzodiazepine w/ Buprenorphine Renewal

Botox - Initial

Botox - Renewal

Buprenorphine - Initial

Buprenorphine - Renewal

Byetta - Initial

Byetta - Renewal

Cimzia

CNS Stimulants - Initial

CNS Stimulants - Renewal

Combivent Respimat

Constipation Agents Initial

Constipation Agents Renewal

Copaxone

Emcyt -  Initial

Emcyt -  Renewal

Enbrel - Initial 

Enbrel - Renewal

Epclusa

Forteo - Initial

Forteo - Renewal

Fuzeon - Initial

Fuzeon - Renewal

Gilenya - Initial

Gilenya - Renewal

Gleevec - Intial

Gleevec - Renewal

Harvoni 

Humira

Iclusig - Initial

Iclusig - Renewal

Isotretinoin

Invega Sustenna - Initial

Invega Sustenna - Renewal

Invega Trinza - Initial

Invega Trinza - Renewal

Janumet - Initial

Janumet - Renewal 

Janumet XR - Initial

Janumet XR - Renewal

Leukeran - Initial

Leukeran - Renewal

Lupron Depot Pediatric - Initial

Lupron Depot Pediatric - Renewal

Lupron Depot for Females - Initial

Lupron Depot for Females - Renewal

Lupron Depot-Eligard for Men - Initial

Lupron Depot-Eligard for Men - Renewal

Lyrica 

Makena

Marinol

Mavyret

Megace

Narcotic Analgesics Over 21

Narcotic Analgesics Under 21

Narcotic Duplication of Therapy

Neulasta

Neupogen

Nexavar

Non-Formulary Drug

Norditropin - Initial

Norditropin - Renewal

NPlate - Initial

NPlate - Renewal

Nuedexta Initial

Nuedexta Renewal

Opsumit - Initial

Opsumit - Renewal 

Orencia

Orenitram - Initial

Orenitram - Renewal

Oxycontin - Initial 

Oxycontin - Renewal

Oxandrin 

Procrit - Initial 

Procrit - Renewal

Promacta - Initial

Promacta - Renewal

Protopic - Initial

Protopic - Renewal

Pulmozyme

Rebif

Revatio - Initial

Revatio - Renewal

Revlimid - Initial 

Revlimid - Renewal 

Risperdal Consta - Initial

Risperdal Consta - Renewal

Serostim

Simponi

Sprycel - Initial

Sprycel - Renewal

Suboxone - Initial

Suboxone - Renewal

Sutent 

Synagis

Synribo - Initial

Synribo - Renewal

Tabloid - Initial

Tabloid - Renewal

Tarceva

Targretin - Initial

Targretin - Renewal

Tasigna - Initial

Tasigna - Renewal

Tecfidera

Temodar - Initial

Temodar - Renewal

Testosterone Replacement Therapy Initial

Testosterone Replacement Therapy Renewal

Thalomid - Initial

Thalomid - Renewal

Tobi

Tracleer - Initial

Tracleer - Renewal

Tradjenta - Initial 

Tradjenta - Renewal

Tysabri

Valcyte - Initial

Valcyte - Renewal

Victoza - Initial

Victoza - Renewal

Vivitrol - Initial

Vivitrol - Renewal

Votrient - Initial

Votrient - Renewal

Xeloda

Xifaxan Initial

Xifaxan Renewal

Xolair - Initial

Xolair - Renewal

Zelboraf - Initial

Zelboraf - Renewal

Zepatier

Zyvox

 

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