“Prior Authorization” is a term used for select services (e.g., homecare services), items (e.g., Durable Medical Equipment purchases over $500) and prescriptions for some injectable or infusion drugs (e.g., Botox, Soliris, OxyContin) that must be pre-approved by Health Partners Plans. Prior Authorizations are sometimes referred to as “preauthorizations” or “precertifications” – they mean the same thing.

Note: Health Partners Plans requires prior authorizations for select services performed in an outpatient setting, including those performed in the office, short procedure units, ambulatory surgery centers, clinics, and hospital outpatient departments.

Prior Authorization Guidelines

Our Prior Authorization Guidelines provide an up-to-date list of all services requiring prior authorization. Prior authorizations are processed either through our provider portal or eviCore, depending on the type of service. Check out our Prior Authorization Management Tool to identify which services require submission through the provider portal or eviCore.

• Medicaid Prior Authorization Management Tools (reviewed 11/1/24)
• CHIP Prior Authorization Management Tools (reviewed 11/1/24)
• Medicare Prior Authorization Management Tools (reviewed 11/1/24)
• Individual and Family Plans - PA Prior Authorization Management Tools (reviewed 11/1/24)
• Code Level Reference Tool (Reviewed 10/1/2024)

For Health Partners (Medicaid), clinical trial prior authorization requests must include a completed attestation form (MA584). Please click here to download a copy of the form.

eviCore Prior Authorization Lists

• Medical Oncology Supportive Drugs - eviCore (updated 10/1/24)
• eviCore CPT list (updated 5/28/24)
• www.evicore.com

Medical Drugs that require Prior Authorization

• Medical Drugs That Require Prior Authorization (Medicaid and CHIP) (Excel; updated 1/22/24)
• Medical Drugs That Require Prior Authorization (Medicare) (Excel; updated 1/26/2024)
• Medical Drugs That Require Prior Authorization (Individual and Family Plans) (Updated 1/22/2024)

Pharmacy Prior Authorization Request Forms

If you want to request a non-formulary drug or a formulary drug that requires prior authorization, please use the appropriate forms as indicated below.

Health Partners (Medicaid), KidzPartners (CHIP)

• Drug-Specific Prior Authorization Forms (2024) — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
• Non-Formulary Drug Prior Authorization Form — Use this request form if the medication you want to request does not have an associated drug-specific form.
• Fax all completed Health Partners (Medicaid) and KidzPartners (CHIP) prior authorization request forms to 1-866-240-3712.

Jefferson Health Plans (Medicare Advantage)

• Drug-Specific Prior Authorization Forms (2024) — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
• Fax all completed Jefferson Health Plans prior authorization request forms to 1-866-371-3239.

Jefferson Health Plans (Individual and Family Plans)

• Drug-Specific Prior Authorization Forms (2024) — Use the appropriate request form to help ensure that all necessary information is provided for the requested drug.
• Fax all completed IFP prior authorization request forms to 1-833-605-4407.