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:

1. 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. Minnesota Uniform Prior Authorization and Formulary Exception Form
   • c. Site of Care Request for Information Form
2. Fill out the patient section of the form.
3. Ask your doctor to fill in the provider and therapy sections of the form.
4. 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: 21111B Minneapolis, MN 55440-1309.

How to make a Part D coverage determination or redetermination request:

1. Sign in to myHealthPartners
2. Click the “Find a form” link on the Medical Plan Services tab
3. Scroll down to “Medicare Forms” to begin

Other forms

• Growth hormone statement of medical necessity form
• Prescription drug reimbursement form
• Short-term health plan – prescription claim review form