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While browsing the preferred drug list, you probably noticed that some medications are designated as "Prior Approval" or have other types of limits, or may not be listed at all. These drugs may be covered, but only under certain conditions. Requests for prior authorizations and formulary exceptions are submitted by providers. However, you can initiate this review process by asking your provider to complete the Prior Authorization / Exception Form with key medical information and have him/her submit it to HealthPartners.
Prior approval drugs
The prior approval process helps to maintain the overall value of the preferred drug list. New medications may provide significant advantages, but often they provide very little benefit at a much greater cost than existing medications. There is also less experience with these new products and the long-term safety is less well known. In addition, advertising by pharmaceutical companies can help increase the demand for these products. The prior approval system helps us make sure that these newer and more costly medications are used only in situations where they really do provide additional benefits.
Doctors requesting prior approval for a particular drug will fax a coverage request on the patient's behalf. Pharmacy Services will review the request, generally within one to two hours of receiving it. If the request is approved, approval information is entered in the pharmacy billing system to allow any staff or network pharmacy to process the prescription for the member's pharmacy benefit. If the request is not approved, the provider is notified and alternatives are recommended.
Step-therapy drugs
For you to receive step-therapy medications, your doctor must prescribe one medication before trying another. For example, step-therapy may require your doctor to prescribe Drug A before Drug B. If Drug A doesn't work for you, your doctor can prescribe Drug B and it will automatically be covered. If Drug A has not already been prescribed for you, your doctor must specifically request coverage of Drug B on your behalf. Generally, a decision will be made the same day the request is submitted and your doctor will be notified.
Physician-edits (MD)
Certain medications are reserved for a specific group of providers as listed in the formulary. Provider-edits help ensure appropriate medications use by limiting certain medications to providers with expertise in their use. The formulary lists specific physician-edits. Claims from these providers are processed automatically without needing approval. Claims from other providers are subject to limits as described in the Drug Formulary. Exceptions to physician-edits can also be requested by providers.
Quantity Limits (QL)
Quantity limits help ensure the appropriate use of medications, and are specified in the formulary.
Quantity limits are applied for safety reasons (such as limiting products containing acetaminophen to maximum safe limits) and for cost reasons (such as promoting fewer tablets per day for medications that are usually given once-daily). Exceptions (needing a greater quantity) can be requested by providers.
Age-edits (AGE)
Age-edits help assure the appropriate use of medications and can simplify the request process for some medications. Age-edit medications are available without restrictions for patients within specific age groups. Age criteria are listed in the Drug Formulary. Patients outside of the specified age group need to meet specific criteria before the medication is approved, and need to use the prior authorization process to submit this information.
Non-preferred Drugs
Some medications are not listed at all. Coverage for these medications can be requested by providers as a formulary exception. Members can initiate this review process by asking their provider to submit a request using the Prior Authorization / Exception Form. Decisions are made on case-by-case basis after consideration of such things as the diagnosis, previous medication history, evidence of efficacy, and medical necessity.
Appeals
You have rights to appeal coverage decisions regarding prior approval and step-therapy. These rights are spelled out in your plan documents. If you have questions about your appeal rights, please contact Member Services.
Additional criteria notes
Information regarding prior approval and step-therapy coverage criteria is regularly updated and is subject to change without notice. HealthPartners reserves the right to publish additional and revised prior approval and step-therapy coverage criteria without specific notice to members.
Consult your plan documents (Membership Contract or Summary Plan Description) to determine governing contractual provisions, including exclusions and limitations relating to your specific plan. These criteria apply to most, but not all, plans offered by HealthPartners. We strive to ensure that the contents of this site are correct and complete, but to verify your benefits, please check your plan documents, or contact Member Services. In the event of a conflict between your specific plan documents and this general information, the plan documents will govern.
These criteria are highly technical and written to assist medical personnel in making coverage determinations. They are not medical advice.
These criteria in no way imply that you should not receive specific services based on the recommendation of your provider. The providers treating you are responsible for medical advice and treatment of patients. If you have specific healthcare needs, you should consult an appropriate healthcare professional.
In those cases where interpretation of some or all of the parts of these criteria is required, HealthPartners medical personnel determine how the criteria, or specific parts of these criteria, apply to your specific situation.
This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage criteria are subject to applicable laws and regulations. Your coverage is contingent on all the applicable terms, conditions, limitations and exclusions of your plan documents.
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