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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 23 of 340 policies
Policy name Policy category Product Prior authorization required
Ibalizumab-uiyk (Trogarzo™) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
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
Immunomodulators (Actemra®, Cimzia®, Entyvio®, Inflectra®, Orencia®, Remicade®, Renflexis®, Simponi Aria®) - Minnesota Health Care Programs Pharmacy
MHCP
Yes
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
Inotuzumab ozogamicin (Besponsa™) – 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
Intensive residential treatment services (IRTS) – Minnesota Health Care Programs Behavioral Health
MHCP
Yes
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
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Ipilimumab (Yervoy®) – Minnesota Health Care Programs Pharmacy
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 23 of 340 policies