Minnesota law requires prescribers to use one uniform form for prescription drug formulary exceptions and requires all payers to accept it; the same form serves drug prior authorization requests. Prescribers meet it when a health plan, HMO or PBM requires approval or an exception and the request is not sent through electronic PA. Payers can reply on the form's Section G with their determination.
The prescriber, or someone authorized to act for them, completes Sections A to F as applicable: destination payer, patient, prescriber, drug, clinical information and pharmacy. The payer completes Section G, and payers posting the form may pre-fill Section A.
Download the current version from the source each time; forms change without notice.
Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes for formulary exceptions: Minnesota Statutes 62J.497 subd. 4 requires providers to use the uniform form and payers to accept it. The same form serves prescription drug PA requests, which the law otherwise requires to be exchanged electronically through the NCPDP SCRIPT standard.
Yes. The form's instructions tell prescribers to complete Section F, pharmacy information including the NDC, when submitting a drug PA request to the Minnesota Department of Human Services, and note that DHS does not cover clinical drug trials.