Coverage criteria

HealthPartners has medical policies that contain criteria describing how we make coverage decisions for health care services and items. Which coverage criteria apply to your plan depends on which state you or your employer bought your plan in (which might not necessarily be the state you live in). For example, if you live in Wisconsin but your employer is based in Minnesota and bought their insurance there, then Minnesota’s coverage applies to the plan. Which coverage criteria will apply is different if you have a Medicare, MinnesotaCare or Medical Assistance (Medicaid) plan.

We update our coverage criteria regularly and they’re subject to change without notice. For more information, see our coverage criteria terms and conditions.

Sign in to your online account to look at your plan’s information. Contact Member Services if you have any questions. Otherwise, you can use the tool here to search by keyword and filter by product. Criteria won’t apply to Medicare unless Medicare is listed in the product column. This also applies to Minnesota Health Care Programs (PMAP, MinnesotaCare, SNBC, MSC+ and MSHO).

See latest medical policy updates

Coverage criteria for Medicare plans

The following coverage rules determine which coverage policies apply to Medicare Cost and Medicare Advantage plans:

Coverage criteria on this site are not applicable to Medicare unless specifically designated. Only services and items listed in the Medicare prior authorization (PA) lists (PDF) require authorization.

Search our coverage criteria

You can search by keyword and apply filters to narrow down your results.

Search tip: If you’re not sure of a keyword’s spelling, type the first three letters of the word followed by an asterisk: *. For example, typing acu* will narrow down the results to acupuncture and other results with that letter combination.

Policy search filters

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 33 of 412 policies
Policy name Policy category Product Prior authorization required
Abatacept (Orencia®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Acupuncture Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Acupuncture – Minnesota Health Care Programs Ancillary Services
MHCP
No
Aducanumab (Aduhelm™) and Lecanemab (Leqembi®) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (generic, Remodulin® and Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (generic, Remodulin® and Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Afamelanotide (Scenesse®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Aflibercept (Eylea®, Eylea® HD), brolucizumab-dbll (Beovu®), and ranibizumab (Lucentis®), ranibizumab-eqrn (Cimerli™), ranibizumab-nuna (Byooviz™) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Airway clearance system / high frequency chest wall compression system Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Airway clearance system/ high frequency chest wall compression system – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Alemtuzumab (Lemtrada™) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Alemtuzumab (Lemtrada™) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Allergy testing/immunotherapy Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Allogeneic processed thymus tissue–agdc (RETHYMIC®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast NP®, Glassia®, Prolastin-C®, and Zemaira®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast NP®, Glassia®, Prolastin-C®, and Zemaira®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Ambulance and medical transportation Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Ambulance and medical transportation - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Amyloid monoclonal antibodies Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Anesthesia services for routine gastrointestinal endoscopic procedures Administrative
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Anifrolumab (Saphnelo®) and belimumab (Benlysta®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Anifrolumab (Saphnelo®) and belimumab (Benlysta®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Artificial intervertebral disc replacement Medical Services
Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Asparaginase erwinia chrysanthemi (recombinant) - rywn (Rylaze™) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Atypical antipsychotic injections (Aristada™, and Zyprexa® Relprevv™) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Augmentative communication device Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Augmentative communication device - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Authorized care outside the service area Ancillary Services
Minnesota
No
Autism - applied behavioral analysis for treatment of autism spectrum disorders Behavioral Health
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Autism - early intensive developmental and behavioral intervention (EIDBI) – Minnesota Health Care Programs Behavioral Health
MHCP
Yes
Autologous chondrocyte implantation (ACI) Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Automatic external defibrillator Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Automatic external defibrillator – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 33 of 412 policies