Pharmacy

This pharmacy section provides resource information to providers specific to formulary and pharmacy benefits.

Medicare Pharmacy Information

DocumentLink
2022
Link
2023
List of Covered Drugs (Comprehensive Formulary) for AbilityCare (SNBC) and SeniorCare Complete (MSHO)PDFPDF
Prior Authorization Criteria
Explains requirements for approval of drugs requiring prior authorization.
PDFPDF
Step Therapy Criteria
Explains requirements for drugs requiring step therapy.
PDFPDF
Request for Medicare Prescription Drug Coverage Determination
This form is used to ask for coverage of a specific drug.
Online form (External link) or PDF
Request for Redetermination of Medicare Prescription Drug Denial
This form is used to appeal a coverage request that has been denied.
Online form (External link) or PDF
Part D Prescription Claim Form
This form is used to get reimbursed for a plan covered drug that a member pays for out of pocket.
PDF
Shingles Vaccine Claim FormPDF
Shingles Vaccine Billing ProcessPDF
Limited Income Newly Eligible Transition ProgramPDF

Medicaid Pharmacy Information

DocumentLink
List of Covered Drugs (Formulary) for South Country programs: Families and Children (PMAP), MinnesotaCare, MSC+, SingleCare, and SharedCare.PDF
Minnesota Uniform Preferred Drug List effective September 1, 2022PDF
Prior Authorization CriteriaPDF
Medicaid Online Prior Authorization Request FormOnline form (External Link)
Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary ExceptionsPDF
Opioid Dependence Agents Pharmacy Prior Authorization FormPDF
Medicaid Opioid Request FormPDF
Medicaid List of Specialty DrugsPDF

Other Resources

Pharmacy Help Desk

PerformRx

Medicaid Help Desk 1-866-935-8874
Medicare Help Desk 1-866-935-6681

Pharmacy Claims

Medicaid BIN# 019595 PCN 06180000
Medicare BIN# 019587 PCN 06190000

Completed UCFs should be mailed to:
PerformRx, P.O. Box 516, Essington, PA 19029

Online Drug Search Links

Medical Assistance (Medicaid) Programs
Families and Children (PMAP)
MinnesotaCare
MSC+
SingleCare (SNBC)
SharedCare (SNBC)

Medicare Advantage Programs
SeniorCare Complete (HMO SNP)
AbilityCare (HMO SNP)

A Provider Toolkit: Meeting the Challenges of Opioids and PAIN

Download Toolkit

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