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.
- Medical Services Prior Authorization List
- Medicare Advantage Medical Service Prior Authorization list (MA)
- Medication (Pharmacy) Prior Authorization
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.
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Medical Services |
Pharmacy (Medication) |
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Provider Portal |
provider.sanfordhealthplan.org - Requires provider account - Provides current status and timely notifications |
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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
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| 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 FormulariesSanford 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:
- Simplicity and TRUE for Individual & Small Groups
- 3-Tier Commercial (Large Group/Self-Funded)
- 5-Tier Commercial (Large Group/Self-funded)
- North Dakota Public Employee Retirement System (NDPERS) Formulary
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.
Peer to Peer Review Requests
Sanford Health Plan has an option available for a peer-to-peer discussion on initial denials between the requesting providers and a Plan physician or pharmacist.
The peer to peer discussion provides an opportunity for a collaborative clinical discussion on:
- Clinical documentation submitted and reviewed
- Clinical criteria used to make the determination
- Allows the provider to provide additional information on the request and any other relevant clinical support for the request
Providers can request a peer to peer within 14 days of the initial determination. Once the peer to peer request is received, Sanford Health Plan will schedule urgent peer-to-peer requests within one business day and routine peer to peer requests within 14 calendar days.
If you would like to schedule a peer-to-peer review, complete and submit the form below to our Utilization Management team. Someone will be in contact to coordinate a time for the peer to peer.
Fill out the Peer to Peer Review Request Form
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.
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Commercial, Self-funded or Sanford Group Health |
Medicare Advantage: Align powered by Sanford Health Plan |
North Dakota Public Employees Retirement System (NDPERS) |
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Business Hours: Utilization Management Pharmacy Management |
Business Hours: Utilization Management Pharmacy Management |
Business Hours: Utilization Management Pharmacy Management |