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Coverage criteria policies

HealthPartners has Medical Policies that contain coverage criteria that describe how we make coverage decisions for certain health care 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…

Medicare plans

For Medicare coverage criteria, click here.

For a list of services requiring Medicare prior authorization, click here.

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

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 27 of 324 policies
Policy name Policy category Product Prior authorization required
Abatacept (Orencia®) Pharmacy
Iowa
Minnesota
Wisconsin
Yes
Abatacept (Orencia®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Access to out-of-network behavioral health services Behavioral Health
MHCP
Minnesota
Yes
Acupuncture Ancillary Services
Iowa
Minnesota
No
Acupuncture - Minnesota Health Care Programs Ancillary Services
MHCP
No
Acupuncture - Wisconsin Ancillary Services
Wisconsin
No
Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® and Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®) Pharmacy
Iowa
MHCP
Minnesota
Wisconsin
Yes
Agalsidase beta (Fabrazyme®) Pharmacy
Iowa
Minnesota
Wisconsin
Yes
Agalsidase beta (Fabrazyme®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Airway clearance system / chest compression generator system Equipment/Supplies
Iowa
Minnesota
Wisconsin
Yes
Airway clearance system/chest compression generator system – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Alemtuzumab (Lemtrada") Pharmacy
Iowa
MHCP
Minnesota
Wisconsin
Yes
Allergy testing immunotherapy Medical Services
Iowa
MHCP
Minnesota
Wisconsin
No
Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C®, and Zemaira®) Pharmacy
Iowa
Minnesota
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 & medical transportation Ancillary Services
Administrative
Iowa
Minnesota
Wisconsin
Yes
Ambulance Transportation Services - Minnesota Health Care Programs Ancillary Services
Administrative
MHCP
Yes
Anesthesia services for routine gastrointestinal endoscopic procedures Administrative
Iowa
MHCP
Minnesota
Wisconsin
No
Ankle replacement surgery Surgery
Iowa
MHCP
Minnesota
Wisconsin
Yes
Artificial insemination (AI) or intra-uterine insemination (IUI) Medical Services
Iowa
Minnesota
Wisconsin
No
Artificial insemination (AI) or intrauterine insemination (IUI) – Minnesota Health Care Programs Medical Services
MHCP
No
Artificial intervertebral disc replacement - cervical Medical Services
Spine
Surgery
Iowa
MHCP
Minnesota
Wisconsin
Yes
Artificial intervertebral disc replacement - lumbar Spine
Surgery
Medical Services
Iowa
MHCP
Minnesota
Wisconsin
Yes
Augmentative communication device Equipment/Supplies
Iowa
Minnesota
Wisconsin
No
Augmentative communication device - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Authorized care outside the service area Other
Minnesota
No
Autologous chondrocyte implantation (ACI) Surgery
Iowa
MHCP
Minnesota
Wisconsin
No
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 27 of 324 policies