HealthPartners has Medical Policies that contain coverage criteria that describe how we make coverage decisions for certain healthcare services and items. Which coverage criteria apply to your plan depends upon the state in which the plan was purchased, which is not necessarily your state of residence. For a customized experience, log on to myHealthPartners. For questions, call the Member Services number on the back of your member identification card.
The information regarding coverage guidelines is regularly updated and is subject to change without notice. Read more…
If unsure of the keyword spelling, enter the first three letters of the word followed by an asterisk (*). Example: enter acu* to locate the acupuncture policy.
Policy search filters
| Policy name | Policy category | Product | Prior authorization required |
|---|---|---|---|
| Abatacept (Orencia®) | Pharmacy | HealthPartners Care Minnesota Wisconsin | Yes |
| Abdominoplasty/panniculectomy | Surgery | Minnesota HealthPartners Care Wisconsin | Yes |
| Access to outpatient behavioral health services | Behavioral Health | Minnesota HealthPartners Care | No |
| Actigraphy | Medical Services Investigational | HealthPartners Care Minnesota Wisconsin | No |
| Actinic keratoses treatment | Medical Services | HealthPartners Care Minnesota Wisconsin | No |
| Acupuncture | Ancillary Services | Minnesota | Yes |
| Acupuncture – HealthPartners Care | Ancillary Services | HealthPartners Care | Yes |
| Acupuncture – Wisconsin | Ancillary Services | Wisconsin | No |
| Adoption | Other | HealthPartners Care Minnesota Wisconsin | No |
| Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® & Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®) | Pharmacy | HealthPartners Care Minnesota Wisconsin | Yes |
| Air compressor | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Air-fluidized specialty bed (group III) | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | Yes |
| Airway clearance system/chest compression generator system | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | Yes |
| Albuterol | Equipment/Supplies Pharmacy | HealthPartners Care Minnesota Wisconsin | No |
| Alefacept (Amevive®) | Pharmacy | HealthPartners Care Minnesota Wisconsin | Yes |
| Allergy testing immunotherapy | Medical Services | HealthPartners Care Minnesota Wisconsin | No |
| Alopecia areata treatment | Medical Services | HealthPartners Care Minnesota Wisconsin | No |
| Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast/NP, Glassia®, Prolastin/C and Zemaira®) | Pharmacy | HealthPartners Care Minnesota Wisconsin | Yes |
| Ambu bag | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Ambulance & medical transportation | Ancillary Services | HealthPartners Care Minnesota Wisconsin | No |
| Ankle replacement surgery | Surgery | HealthPartners Care Minnesota Wisconsin | Yes |
| Anti-nausea wristband | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Apnea monitor | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Appliance cleaner | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Aqua K pad and pump | Equipment/Supplies | HealthPartners Care Minnesota Wisconsin | No |
| Arch support – HealthPartners Care | Equipment/Supplies | HealthPartners Care | No |
| Artificial Intervertebral Disc Replacement - Cervical | Surgery Spine Medical Services | Minnesota HealthPartners Care Wisconsin | Yes |
| Artificial insemination (AI) or intra-uterine insemination (IUI) | Medical Services | HealthPartners Care Minnesota Wisconsin | No |
| Artificial intervertebral disc replacement - lumbar | Investigational Spine | HealthPartners Care Minnesota Wisconsin | No |
| Asparaginase Erwinia chrysanthemi (Erwinaze®) | Pharmacy | Minnesota HealthPartners Care Wisconsin | Yes |
| Augmentative communication device | Equipment/Supplies | Minnesota | No |
| Augmentative communication device – HealthPartners Care | Equipment/Supplies | HealthPartners Care | No |
| Authorized care outside the service area | Other | Minnesota | Yes |
| Autologous bone marrow grafting (ABMG) for osteonecrosis | Surgery | HealthPartners Care Minnesota Wisconsin | No |
| Autologous chondrocyte implantation (ACI) | Medical Services | HealthPartners Care Minnesota Wisconsin | No |
| Autologus platelet rich plasma (PRP) injections | Medical Services Investigational | HealthPartners Care Minnesota Wisconsin | No |
| Autopsy | Ancillary Services | HealthPartners Care Minnesota Wisconsin | No |
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