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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

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Viewing 322 of 322 policies
Policy name Policy category Product Prior authorization required
Abatacept (Orencia®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Abatacept (Orencia®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Access to out-of-network behavioral health services Behavioral Health
Iowa
MHCP
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
Adult mental health residential services coverage criteria Behavioral Health
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
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
North Dakota
South Dakota
Wisconsin
Yes
Agalsidase beta (Fabrazyme®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Agalsidase beta (Fabrazyme®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Airway clearance system / chest compression generator system Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Airway clearance system/chest compression generator system – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Alemtuzumab (Lemtrada™) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Allergy testing immunotherapy Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
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
Administrative
Iowa
Minnesota
North Dakota
South Dakota
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
North Dakota
South Dakota
Wisconsin
No
Ankle replacement surgery Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Artificial insemination (AI) or intra-uterine insemination (IUI) Medical Services
Iowa
Minnesota
North Dakota
South Dakota
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
North Dakota
South Dakota
Wisconsin
Yes
Artificial intervertebral disc replacement - lumbar Spine
Surgery
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Artificial pancreas system Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Asparaginase Erwinia chrysanthemi (Erwinaze®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
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 Administrative
Minnesota
No
Autologous chondrocyte implantation (ACI) Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Automatic external defibrillator Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Automatic external defibrillator – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Belimumab (Benlysta®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Belimumab (Benlysta®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Benralizumab (Fasenra) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Bevacizimab (Avastin®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Bezlotoxumab (Zinplava) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Biofeedback - medical applications Ancillary Services
Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Biofeedback for behavioral health applications Behavioral Health
Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Blepharoplasty, blepharoptosis repair, and brow lift Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Blinatumomab (Blincyto™) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Blood factor products Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Blood pressure monitors/units - Minnesota Health Care Programs - retire 1/1/19 Equipment/Supplies
MHCP
No
Blood pressure monitors/units - retire 1/1/19 Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Bone stimulators, electronic and ultrasonic Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Bone stimulators, electronic and ultrasonic - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Botulinum toxins: abobotulinumtoxinA (Dysport®), incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®) and rimabotulinumtoxinB (Myobloc®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Botulinum toxins: abobotulinumtoxinA (Dysport®), incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®), and rimabotulinumtoxinB (Myobloc®) – Minnesota Health Care Programs Pharmacy
MHCP
Yes
Breast prosthesis Administrative
Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Breast pumps Equipment/Supplies
Minnesota
Wisconsin
Yes
Breast pumps - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Breast pumps – Iowa - North Dakota - South Dakota Equipment/Supplies
Iowa
North Dakota
South Dakota
Yes
Breast specific gamma imaging (BSGI) Investigational
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Breast surgery Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Buprenorphine (Probuphine) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Buprenorphine injectable (Sublocade) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Capsule endoscopy Diagnostic Imaging
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Cardiac event monitoring Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Cardiovascular risk assessments Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Category III CPT codes Investigational
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Category III CPT codes – Minnesota Health Care Programs Investigational
MHCP
No
Cerliponase alfa (Brineura) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Certolizumab (Cimzia®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Certolizumab (Cimzia®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Chemical health residential services - Minnesota Health Care Programs Behavioral Health
MHCP
Yes
Chemical health services Behavioral Health
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Children's residential treatment services - Minnesota Health Care Programs Behavioral Health
MHCP
Yes
Chimeric antigen receptor/genetically engineered T-cell receptor (CAR-T) therapy Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Chiropractic services Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Chiropractic services - Minnesota Health Care Programs Medical Services
MHCP
No
Chronic pain - multidisciplinary intensive day treatment programs Behavioral Health
Medical Services
Iowa
Minnesota
Wisconsin
Yes
Circumcision - Minnesota Health Care Programs Surgery
MHCP
Yes
Cleft lip/cleft palate Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Clinical trials - coverage of routine care costs Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Cognitive rehabilitation Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Collagenase (Xiaflex®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Complementary and alternative medicine Administrative
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Compounded medications Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Compression support garments Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Compression support garments - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Computed tomography (CT), Magnetic resonance imaging (MRI) and Positron emission tomography (PET) scans Diagnostic Imaging
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Continuous passive motion (CPM) devices Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Continuous positive airway pressure (CPAP) Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Continuous positive airway pressure (CPAP) - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Cosmetic surgery / treatments Surgery
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Cosmetic surgery/treatments - Iowa Surgery
Iowa
Yes
Court-ordered care - mental health Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Cushions Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Deep brain stimulation for neurological movement disorders Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Denosumab (Prolia® and Xgeva®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - accidental dental Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - ambulatory hospitalization and anesthesia for dental care Medical Dental
Iowa
MHCP
Minnesota
South Dakota
Wisconsin
Yes
Dental services - ambulatory hospitalization and anesthesia for dental care - North Dakota Medical Dental
North Dakota
Yes
Dental services - cone beam computed tomography (CBCT) scan for medically-related dental services Diagnostic Imaging
Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - medically necessary outpatient Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - oral surgery Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dental Services - Orthodontics Medical Dental
Minnesota
Yes
Dental services - orthognathic surgery Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Designated network for children's psychiatric residential treatment services Behavioral Health
MHCP
Minnesota
Wisconsin
Yes
Diabetic monitors/meters Equipment/Supplies
Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dietitian consultation Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Direct-to-consumer (DTC) laboratory testing Administrative
Laboratory
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Discography/intradiscal steroid injections Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
DME benefits grid Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dressing supplies Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Duopa Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Durable medical equipment (DME) and prosthetics Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Durable medical equipment (DME) and supplies – Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Early intensive developmental and behavioral intervention (EIDBI) - Minnesota Health Care Programs Behavioral Health
MHCP
Yes
Early intensive intervention services for autism - MN Behavioral Health
Minnesota
Yes
Eating disorder coverage criteria Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Eculizumab (Soliris®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Eculizumab (Soliris®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Edaravone (Radicava) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Electric tumor treatment fields (ETTF) to treat glioblastoma (Optune)™ Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Electric tumor treatment fields (ETTF) to treat glioblastoma (Optune™) - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Epidural steroid injections (ESI) for low back pain Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Eteplirsen (Exondys 51™) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Eye surgery - refractive Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Eyewear Equipment/Supplies
Administrative
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Eyewear - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Eyewear for children Equipment/Supplies
Minnesota
Wisconsin
No
Feeding/oral function therapy, pediatric Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Foot care Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Formula - amino acid based elemental - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Functional electrical stimulation (FES) in the home Equipment/Supplies
Investigational
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES) - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Gender reassignment surgery Surgery
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Gender-confirming surgery – Minnesota Health Care Programs Surgery
MHCP
Yes
Genetic Testing Ancillary Services
Genetics
Laboratory
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing for Arrhythmias and Cardiomyopathies Laboratory
Genetics
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing for Cancer Predisposition Genetics
Ancillary Services
Laboratory
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing for Connective Tissue, Skeletal, and Integumentary Disorders Laboratory
Genetics
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing for Gastrointestinal Disorders Laboratory
Genetics
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing: Carrier Screening, Prenatal Screening, Prenatal Diagnosis, and Infertility Evaluation Genetics
Laboratory
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Genetic Testing: Coagulation Disorders and Cardiovascular Risk Assessments Laboratory
Genetics
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing: Molecular Profiling Assays for Cancer Management Genetics
Laboratory
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing: Neurological, Developmental, and Sensory Disorders and Congenital Anomalies Genetics
Laboratory
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Genetic Testing: Pharmacogenetics Genetics
Laboratory
Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Golimumab (Simponi ARIA®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Golimumab (Simponi ARIA®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Growth deficiency therapy Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Yes
Growth hormone drugs - Wisconsin Pharmacy
Wisconsin
Yes
Gynecomastia surgery Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Health education Ancillary Services
Administrative
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Hearing aids Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Hearing aids - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Heart failure pressure sensor, implantable (i.e., CardioMEMS HF System) Investigational
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Hemangioma treatment Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Hereditary angioedema (HAE) drug therapy Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Hereditary angioedema (HAE) drug therapy - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Home health service Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Home health service - Minnesota Health Care Programs Ancillary Services
Medical Services
MHCP
Yes
Home hospice services Ancillary Services
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Home hospice services - Iowa Ancillary Services
Iowa
Yes
Home hospice services - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Home phototherapy - full body cabinet Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Home phototherapy - full body cabinet – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Hospital bed Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Hospital bed - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Hyperbaric oxygen therapy Ancillary Services
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Immune globulin therapy Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Immune globulin therapy - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Immunizations Pharmacy
Preventive
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
In vitro fertilization (IVF) and other advanced assisted reproductive technology (ART) Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
In-home mental health psychotherapy services Behavioral Health
Iowa
Minnesota
MHCP
North Dakota
South Dakota
Wisconsin
Yes
In-home mental health psychotherapy services - Minnesota Health Care Programs Behavioral Health
MHCP
Yes
In-network benefit requests Administrative
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Infertility care - Wisconsin Medical Services
Wisconsin
No
Infertility diagnosis and treatment Medical Services
Iowa
Minnesota
North Dakota
South Dakota
No
Infertility diagnosis and treatment – Minnesota Health Care Programs Medical Services
MHCP
No
Infliximab (Remicade®, Inflectra®, Renflexis®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Infliximab (Remicade®, Inflectra®, Renflexis®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Inpatient - behavioral health coverage criteria Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Intensive behavioral therapy for autism - Wisconsin Behavioral Health
Wisconsin
Yes
Intensive early intervention behavioral therapy (IEIBT) Behavioral Health
Iowa
Minnesota
No
Intra-articular hyaluronan (viscosupplementation) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Investigational services Investigational
Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Investigational services - list of non-covered services Behavioral Health
Investigational
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Ipilimumab (Yervoy) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Juvenile court ordered examination Behavioral Health
Medical Services
MHCP
Minnesota
North Dakota
South Dakota
No
Labor charges, repairs and parts for Durable Medical Equipment (DME), including prosthetics and orthotics Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Laser treatment for skin conditions Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Lift chair mechanism Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Lift chair mechanism - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Lyme disease - antibiotic treatment Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Maintenance care Administrative
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Medical cannabis Administrative
Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Medically necessary/ medical necessity Behavioral Health
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Medication therapy disease management program Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Medications for risk reduction of primary breast cancer in women Pharmacy
Preventive
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Mepolizumab (Nucala®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Mesenchymal stem cell therapy for orthopedic indications Investigational
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Minimally invasive and laser spine procedures Spine
Investigational
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Minimum/maximum drug dosage Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Mucopolysaccharidoses (MPS) drug therapy Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Mucopolysaccharidoses (MPS) drug therapy - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Natalizumab (Tysabri®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Natalizumab (Tysabri®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Necitumumab (Portrazza®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Neuromuscular electrical stimulator (NMES) Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Neuropsychological testing Behavioral Health
Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Neuropsychological testing – Minnesota Health Care Programs Behavioral Health
Medical Services
MHCP
No
Non-surgical treatment for gender dysphoria Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Nusinersen (Spinraza) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Nutrition (medical) therapy - Minnesota Health Care Programs Ancillary Services
MHCP
No
Nutritional support Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Nutritional support - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Ocrelizumab (Ocrevus) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Ocrelizumab (Ocrevus) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Omalizumab (Xolair®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Oncology drug coverage Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Oral appliances for sleep disorders Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Oral appliances for sleep disorders – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Orthotics / braces / shoes – Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Orthotics, braces, and shoes Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Outdoor behavioral health programs Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Oxygen Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Panniculectomy Surgery
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Panniculectomy – Minnesota Health Care Programs Surgery
MHCP
Yes
Pectus excavatum and pectus carinatum Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Pegloticase (Krystexxa®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pegloticase (Krystexxa®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Percutaneous tibial nerve stimulation (PTNS) for overactive bladder Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Peripheral nerve block injections - diabetic peripheral neuropathy Investigational
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Personal care assistant (PCA) - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Physical & occupational therapy - rehabilitative-Minnesota Health Care Programs Ancillary Services
MHCP
No
Physical and occupational therapy - habilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Physical and occupational therapy - rehabilitative Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Plerixafor (Mozobil®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pneumatic compression devices and cold/heat therapy units – Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Pneumatic compression devices and heat/cold therapy units Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Pompe disease enzyme replacement therapy - alglucosidase alfa (Myozyme® and Lumizyme®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Pompe disease enzyme replacement therapy – alglucosidase alfa (Myozyme® and Lumizyme®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Port-wine stain treatment Medical Services
MHCP
Minnesota
Wisconsin
No
Port-wine stain treatment – Iowa - North Dakota - South Dakota Medical Services
Iowa
North Dakota
South Dakota
No
Pressure reducing support surfaces Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Preventive services Medical Services
Preventive
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Private duty aide in hospital or skilled nursing facility Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Prophylactic mastectomy Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Prosthesis - lower limb Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Prosthesis - upper limb Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Protective helmets Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Protective helmets – Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Proton beam radiation therapy Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck and back pain Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Recent Food and Drug Administration (FDA) approved medications coverage policy Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Reconstructive surgery Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Reduction mammaplasty Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Repetitive transcranial magnetic stimulation Behavioral Health
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Repetitive transcranial magnetic stimulation - Minnesota Health Care Programs Behavioral Health
MHCP
No
Reslizumab (Cinqair®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Rhinoplasty and septorhinoplasty Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Rituximab (Rituxan®, Rituxan Hycela®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Sacral nerve stimulation for fecal incontinence Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Sacroiliac joint pain treatment procedures Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Scar revision/keloids Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Sebelipase Alfa (Kanuma) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Sex therapy, sexual dysfunctions and paraphilic disorders Behavioral Health
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Skilled nursing facility Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Skilled nursing facility - Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Sleep studies Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Sleep studies - Minnesota Health Care Programs Medical Services
MHCP
No
Somatostatin analogues for acromegaly (Sandostatin LAR®, Somatuline Depot®, Signifor LAR®, Somavert®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Speech therapy - habilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Speech therapy - rehabilitative Ancillary Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Speech therapy - Rehabilitative - Minnesota Health Care Programs Ancillary Services
MHCP
No
Spinal cord and implanted peripheral nerve stimulation Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Spinal fusion, lumbar Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Spinal lumbar laminectomy Medical Services
Spine
Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Spinal unloading devices Equipment/Supplies
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Spine surgical practice - low back pain office visits Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Statin medications for prevention of cardiovascular disease Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Stereotactic radiosurgery and stereotactic body radiation therapy Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Sublingual immunotherapy (SLIT) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Supprelin LA/Lupron Depot-Peds - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Sympathectomy (thoracic) for the treatment of primary hyperhidrosis Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Synagis (palivizumab) injections for respiratory syncytial virus (RSV) prophylaxis Medical Services
Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Targeted case management eligibility - adult - Minnesota Health Care Programs Behavioral Health
MHCP
No
Targeted case management eligibility - child - Minnesota Health Care Programs Behavioral Health
MHCP
No
Telehealth Administrative
Iowa
MHCP
Minnesota
South Dakota
Wisconsin
No
Telehealth - North Dakota Administrative
North Dakota
No
Telemedicine - Minnesota Health Care Programs Administrative
MHCP
No
Temporomandibular disorder (TMD) treatments Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Termination of pregnancy Administrative
Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Termination of pregnancy - Minnesota Health Care Programs Administrative
Medical Services
MHCP
No
Third party payments Administrative
Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Tick borne illness laboratory testing Laboratory
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Tocilizumab (Actemra®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Tocilizumab (Actemra®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Transcutaneous electrical nerve stimulator (TENS) unit Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Transcutaneous electrical nerve stimulator (TENS) unit - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Transplant travel benefits Administrative
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Transplants Transplants
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Type I Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme®), velaglucerase (Vpriv®), telaglucerase (Elelyso®) and eliglustat tartrate (Cerdelga®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Type I Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme®), velaglucerase (Vpriv®), telaglucerase (Elelyso®) and eliglustat tartrate (Cerdelga®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Upper airway stimulation - hypoglossal nerve stimulation therapy for obstructive sleep apnea (i.e., Inspire Device) Investigational
Medical Services
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Ustekinumab (Stelara®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Ustekinumab (Stelara®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Vagus Nerve Stimulation (VNS) Behavioral Health
Surgery
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Varicose vein procedures Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Vedolizumab (Entyvio®) Pharmacy
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Vedolizumab (Entyvio®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
Ventricular assist devices (VADs) & Total artificial hearts Surgery
Transplants
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Ventricular Assist Devices (VADs) & Total Artificial Hearts – Minnesota Health Care Programs Surgery
Transplants
MHCP
Yes
Vision care services Medical Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Vision care services - Minnesota Health Care Programs Medical Services
MHCP
No
Vision therapy / orthoptics Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Vision therapy / orthoptics – Minnesota Health Care Programs Ancillary Services
MHCP
Yes
Voretigene neparvovec-rzyl (Luxturna™) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Walkers Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Walkers - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
Weight loss management Ancillary Services
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Weight loss surgery Surgery
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Weight loss surgery - Iowa Surgery
Iowa
Yes
Weight loss surgery-re-operations Surgery
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Weight loss surgery-re-operations - Iowa Surgery
Iowa
Yes
Wheelchairs - mobility assistive equipment (MAE) Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Wheelchairs - mobility assistive equipment (MAE) - Minnesota Health Care Programs Equipment/Supplies
MHCP
Yes
Wigs Equipment/Supplies
MHCP
Minnesota
Yes
Wigs - Iowa Equipment/Supplies
Iowa
Yes
Wigs - North Dakota - South Dakota - Wisconsin Equipment/Supplies
North Dakota
South Dakota
Wisconsin
No
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