Medical Services & Drug Prior Authorization

NOTE: This page does not apply to Great Plains Medicare Advantage (I-SNP) plans. Refer to that website for details here.

Prior Authorization (pre-approval, preauthorization or precertification): A request that must be submitted for approval of certain procedures, hospitalizations, medications and out-of-network services before they are received (except in an emergency). Sanford Health Plan will review the request to determine if it is appropriate and medically necessary. Prior authorization does not guarantee the Plan will cover the service and will be based on the Member’s benefit plan and eligibility.

  • Please refer to Prior Authorization list(s) for services that require prior authorization.
  • Prior Authorization may be obtained by the member or provider on the member’s behalf.
  • Oncology treatment (chemotherapy and radiation) must be submitted by the provider through eviti| Connect at eviti.com.
  • High Tech Imaging for select members and health plans to be submitted thru eviCore Provider Portal link here.

What Requires Prior Authorization

The following services and medications require prior authorization. These lists are subject to change based upon Sanford Health Plan Medical Management Policy updates, and the specifics for some plans may vary slightly.

Locate a Provider or Pharmacy

Find a provider or pharmacy in Sanford Health Plan’s networks.

How to Request Prior Authorization

Members may work with their provider to submit a prior authorization or formulary exception request.

Medical Services

Pharmacy (Medication)

Provider Portal

provider.sanfordhealthplan.org

- Requires provider account

- Provides current status and timely notifications

Prior Authorization Form

Medical Services Prior Authorization Request Form

Out of Network Prior Authorization Request Form

Medicare Advantage (Align) Medical Services Prior Authorization request form

Medication (Pharmacy) Prior Authorization Request or Formulary Exception Form

 

Synagis Prior Authorization Form (for Synagis ONLY)
 Great Plains Medicare Advantage **For GPMA (I-SNP) please go to the GPMA Provider and Partner webpage here.
 Medicare Advantage  **For MA (MAPD) please go to the form webpage here.

 

Additional Pharmacy Information

*Note: Align powered by Sanford Health Plan Pharmacy information is located here.

Drug Formularies

Sanford Health Plan has a list (formulary) of FDA approved brand name and generic medications that are covered by the Plan. By following the formulary and using generic medications when available, members can save money and help control out of pocket costs.

Sanford Health Plan Formularies:

If a medication is not on the formulary, an exception can be made if:

  • A provider feels it is medically necessary; or
  • The member has tried and failed the formulary option(s).

Medication Benefits

For medications to be considered for coverage, they must be:

  • Approved by the Federal Food and Drug Administration (FDA) for use in the United States;
  • Prescribed or approved by a physician, advanced practice provider or dentist;
  • Listed in the plan formulary, unless pre-approval (authorization) is given by the plan;
  • Provided by an in-network participating pharmacy except in the event of a medical emergency; NOTE: If a prescription is filled at a non-participating and/or out-of-network pharmacy and it is not an emergency, the member is responsible for the prescription drug cost in full.

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    Contact Us

    Sanford Health Plan staff are available by calling the appropriate number below. After hours, you may leave a message on the confidential voice mail and someone will return your call the following business day. Questions may also be sent via secure message through the provider and member portals.

    Commercial, Self-funded or

    Sanford Group Health

    Medicare Advantage: Align powered by Sanford Health Plan

    North Dakota Public Employees Retirement System (NDPERS)

    Business Hours:
    8 a.m. to 5 p.m. CST
    Monday-Friday


    Utilization Management
    (Medical Services)
    Phone: (800) 805-7938
    Fax: (605) 328-6813


    Pharmacy Management
    (Medication Benefits)
    Phone: (855) 305-5062
    Fax: (701) 234-4568

    Business Hours:
    8 a.m. to 5 p.m. CST
    Monday-Friday


    Utilization Management
    (Medical Services)
    Phone: (800) 805-7938
    Fax: (605) 328-6813


    Pharmacy Management
    (Medication Benefits)
    Phone: (844) 642-9090

    Business Hours:
    8 a.m. to 5:30 p.m. CST
    Monday-Friday


    Utilization Management
    (Medical Services)
    Phone: (888) 315-0885
    Fax: (605) 328-6813


    Pharmacy Management
    (Medication Benefits)
    Phone: (877) 658-9194
    Fax: (701) 234-4568