Forms

Prior Authorization/Formulary Exception

If you have a medicine that requires a formulary exception or Prior Approval, follow the instructions below. Or, you can call Member Services at the number on the back of your Member ID card to start the Prior Approval/exception process.

Prior Authorization / Exception Form
Minnesota Uniform Prior Authorization and Formulary Exception Form
Online Part D Coverage Determination or Redetermination request - Click on the 'Find a form' link on the Medical Plan Services tab, then scroll down to 'Medicare Forms' to begin.

How to complete the Prior Authorization/exception form:

• Step 1: Print the form.


• Step 2: Fill out the patient section of the form.


• Step 3: Have your doctor fill in the provider and requested therapy sections of the form. He or she has to complete this part for the form to be reviewed.


• Step 4: Ask your doctor to fax the form from his or her office to us at 888-883-5434 (also listed at the top of the form) or mail the form to: HealthPartners, P.O. Box 1309, Mail Stop: 21111B Minneapolis, MN 55440-1309.

Mail Order Forms

myMailRx Pharmacy Prescription Order Form
Over-the-counter Mail Order Form

Other Forms

Consent to Arrange for Payment and Release Information Form
Explanation of Consent Form
Growth Hormone Statement of Medical Necessity Form
Prescription Drug Reimbursement Form
Short Term Health Plan - Prescription Claim Review Form

Do you have two health plans that cover your pharmacy claims?

If HealthPartners is the secondary plan, your pharmacy can now bill your secondary claims online. Simply show your pharmacy the membership card of your primary health plan along with your HealthPartners Member ID card. The pharmacy will do the rest! This will eliminate the needing to file a paper claim to be reimbursed for your copay.