Prescription Drug Prior Authorization (PA) Form

Please Note:

Minnesota Statutes 62J.497 was amended during the 2009 legislative session with requirements for the Minnesota Department of Health (MDH) to produce an “outline on how best to standardize drug prior authorization request transactions between providers and group purchasers with the goal of maximizing administrative simplification and efficiency in preparation for electronic transmissions.” This requirement was fulfilled with a report, submitted 2/15/2010, which includes a section describing a form to be used for prescription drug PA requests.  The form for PA requests was very similar to another form that MDH developed, for formulary exception requests.  Because of the similarities between the two forms, MDH has created a single, combined prescription drug PA and formulary exception request form:  the Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions.  This single, combined form supersedes all previous versions.

Minnesota Laws, Chapter 336, Sec. 5, requires that “No later than January 1, 2015, drug prior authorization requests must be accessible and submitted by health care providers, and accepted by group purchasers, electronically through secure electronic transmissions. Facsimile shall not be considered electronic transmission.”

Please see the instructions page of the Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions for further instructions.


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Updated Monday, 29-Jul-2013 12:04:59 CDT