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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.

Actemra- Initial

Actemra- Renewal

Adcirca - Initial

Adcirca - Renewal

Aimovig- Initial

Aimovig- Renewal

Ampyra - Initial

Ampyra - Renewal

Antidiabetic Agents, Injectable - Initial

Antidiabetic Agents, Injectable - Renewal

Antidiabetic Agents, Oral - Initial

Antidiabetic Agents, Oral - Renewal

Atypical Antipsychotics Under 18 - Initial

Atypical Antipsychotics Under 18 - Renewal

Avonex

Benzodiazepine w/ Buprenorphine - Initial

Benzodiazepine w/ Buprenorphine - Renewal

Botox - Initial

Botox - Renewal

Buprenorphine Med Assisted Treatment- Initial

Buprenorphine Med Assisted Treatment - Renewal

Cimzia

CNS Stimulants - Initial

CNS Stimulants - Renewal

Constipation Agents - Initial

Constipation Agents - Renewal

Deferasirox - Initial

Deferasirox - Renewal

Dupixent- Initial

Dupixent - Renewal

Enbrel

Enoxaparin

Entresto

Epclusa

Fasenra - Initial

Fasenra - Renewal

Filgrastim Agents

Forteo - Initial

Forteo - Renewal

Fuzeon - Initial

Fuzeon - Renewal

Gender Dysphoria

Gilenya - Initial

Gilenya - Renewal

Glatiramer

Growth Hormones - Initial

Growth Hormones - Renewal

H.P. Acthar Gel Initial

H.P. Acthar Gel Renewal

Harvoni

Humira

Humulin R U-500 Vial - Initial

Humulin R U-500 Vial - Renewal

Isotretinoin

Ingrezza - Initial

Ingrezza - Renewal

Letairis - Initial

Letairis - Renewal

Long-Acting Injectables Antipsychotics - Initial

Long-Acting Injectables Antipsychotics - 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 ES 

Modafinil Agents - Initial

Modafinil Agents - Renewal

Narcotic Analgesics

Narcotic Duplication of Therapy

Non-Formulary Drug

Nucala - Initial

Nucala - Renewal

Nuedexta - Initial

Nuedexta - Renewal

Opsumit - Initial

Opsumit - Renewal 

Oral Chemotherapy Agents - Initial

Oral Chemotherapy Agents - Renewal

Orencia

Orenitram - Initial

Orenitram - Renewal

Oxandrin 

Procrit

Promacta - Initial

Promacta - Renewal

Pulmozyme

Rebif

Repatha - Initial

Repatha - Renewal

Revatio (sildenafil) - Initial

Revatio (sildenafil) - Renewal

Serostim

Simponi

Synagis

Targretin gel - Initial

Targretin gel - Renewal

Tecfidera

Testosterone Replacement Therapy - Initial

Testosterone Replacement Therapy - Renewal

Tobramycin

Tracleer - Initial

Tracleer - Renewal

Tysabri

Valcyte - Initial

Valcyte - Renewal

Xifaxan - Initial

Xifaxan - Renewal

Xolair - Initial

Xolair - Renewal

Xyrem

Zyvox