This pharmacy section provides resource information to providers specific to formulary and pharmacy benefits.
Medicare Pharmacy Information
| Document | Link 2023 |
|---|---|
| List of Covered Drugs (Comprehensive Formulary) for AbilityCare (SNBC) and SeniorCare Complete (MSHO) | |
| Prior Authorization Criteria Explains requirements for approval of drugs requiring prior authorization. | |
| Step Therapy Criteria Explains requirements for drugs requiring step therapy. | |
| 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. | |
| Shingles Vaccine Claim Form | |
| Shingles Vaccine Billing Process | |
| Limited Income Newly Eligible Transition Program | "PDF" |
| Preferred Diabetic Supplies |
Medicaid Pharmacy Information
| Document | Link |
|---|---|
| List of Covered Drugs (Formulary) for South Country programs: Families and Children (PMAP), MinnesotaCare, MSC+, SingleCare and SharedCare. | |
| Minnesota Uniform Preferred Drug List effective September 15, 2023 | |
| Prior Authorization Criteria | |
| Medicaid Online Prior Authorization Request Form | Online form (External Link) |
| Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions | |
| Opioid Dependence Agents Pharmacy Prior Authorization Form | |
| Medicaid Opioid Request Form | |
| Medicaid List of Specialty Drugs |
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)