HealthPartners pharmacy forms
Requesting an exception to the drug list
If you take a medicine that isn’t on the drug list, you can request to have the medicine covered by your insurance. This is called requesting a prior authorization or a formulary exception. Follow the steps below or contact Member Services to start the process. (Tell them you would like to start the prior authorization or exception process.)
How to request an exception:
- Print the appropriate form from the list below. Not sure which form you need? Call Member Services using the phone number on the back of your Member ID card.
- a. Prior Authorization / Exception Form
- b. Opioid Medication Request Form
- c. Stimulant Medication Request Form
- d. Hepatitis C Medication Request Form
- e. Hepatitis C Medication Reauthorization Request Form
- f. High Dose of Benzodiazepine Medications Request Form
- g. Minnesota Uniform Prior Authorization and Formulary Exception Form
- h. Rare Disease Medication Coverage Request Form
- i. Chronic Inflammatory Disease Biologic Annual Reauthorization & High Dose Request Form
- j. Site of Care Request for Information Form
- Fill out the patient section of the form.
- Ask your doctor to fill in the provider and therapy sections of the form.
- Ask your doctor to fax the form to 888-883-5434 or mail the form to us.
- a. Mail it to this address: HealthPartners, P.O. Box 1309, Mail Stop: 22205A Minneapolis, MN 55440-1309.
How to make a Part D coverage determination or redetermination request:
- Log on to myHealthPartners
- Click the “Find a form” link on the Medical Plan Services tab
- Scroll down to “Medicare Forms” to begin
- Growth hormone statement of medical necessity form
- Prescription drug reimbursement form
- Short-term health plan – prescription claim review form