Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions

Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions

The Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions is described below.  Use the most recent version of the Minnesota Uniform Form For Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions form (PDF).

Intended use and requirements:
The form is intended primarily for use pursuant to state law by prescribers, or those designated and authorized to act on behalf of prescribers, to:

1. Request an exception to a prescription drug formulary.
  • Requests for formulary exceptions are requests to make nonformulary prescription drugs available to a patient as a formulary drug.
    • Minnesota Statutes, section 62J.497, Subd. 4 requires that all health care providers must submit requests for formulary exceptions using the uniform form, and that all payers must accept this form from health care providers. No later than January 1, 2011, the uniform formulary exception form must be accessible and submitted by health care providers, and accepted and processed by group purchasers, through secure electronic transmissions. Note: A previous restriction in law that facsimile was not considered “secure electronic transmission” was removed in 2010.

2. Request a prior authorization (PA) for a prescription drug.

  • Prescription drug prior authorization requests are requests for pre-approval from a payer for specified medications or quantities of medications.
    • Minnesota Statutes, section 62J.497, Subd. 5 requires that by January 1, 2015, drug PA requests must be accessible and submitted by health care providers, and accepted by payers, electronically through secure electronic transmissions.

PLEASE NOTE:  Minnesota Statutes, section 62J.497 Subd.5(c) also requires that “No later than January 1, 2016, 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.” An Electronic Prior Authorization Factsheet (PDF) with additional information regarding this statutory provision, as well as other information regarding e-prescribing, is available on the Minnesota Department of Health’s “Electronic Prescribing in Minnesota” webpage.

Updated Thursday, July 13, 2017 at 08:45AM