Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Pharmacy

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

Medicare Pharmacy Information

DocumentLink
Link
2026
List of Covered Drugs (Comprehensive Formulary) for AbilityCare (SNBC) and SeniorCare Complete (MSHO)English PDF
Español PDF
Soomaali PDF		PDF (English)
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.		Submit an Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool software, or through any of the following online portals:
CoverMyMeds (external link)
SureScripts (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.		Submit an Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool software, or through any of the following online portals:
CoverMyMeds (external link)
SureScripts (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
Preferred Diabetic SuppliesPDFPDF

Medicaid Pharmacy Information

DocumentLink
List of Covered Drugs (Formulary) for South Country programs: Families and Children (PMAP), MinnesotaCare, MSC+, SingleCare and SharedCare.English PDF
Soomaali PDF
Español PDF
Minnesota Uniform Preferred Drug List effective January 1, 2025 PDF (External Link)
Prior Authorization CriteriaPDF
Medicaid Online Prior Authorization Request FormSubmit an Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool software, or through any of the following online portals:
CoverMyMeds (external link)
SureScripts (external link)
Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary ExceptionsPDF
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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