Pharmacy prior authorization and other resources

Refer to these drug and other pharmacy resources for additional information.

Pharmacies and prescribing providers must submit all drug authorization requests to Prime Therapeutics, the Minnesota Health Care Programs (MHCP) prescription drug prior authorization (PA) agent, by phone at 844-575-7887, or by fax at 866-390-2778, or through electronic PA. Refer to the Prime Therapeutics Provider Manual (PDF) for additional information.

Prior authorization forms and instructions

• Prescription Drug Prior Authorization Form 
• Prescription Drug Reconsideration Request Form
• MHCP Authorization Form (DHS-4695) (PDF)
• Synagis Prior Authorization Form
• Advance Recipient Notice of Non-covered Service/Item (DHS-3640) (PDF)
• Advance Recipient Notice of Non-covered Prescription (DHS-3641) (PDF)

Additional resources

• HCPCS codes requiring NDC
• State MAC List Updated frequently
• Maximum Allowable Cost Price Research Request Form
• Minnesota Health Care Programs Pharmacy Modernization Module NCPDP D.0 Payer Specifications Claim Billing (PDF) (effective Nov. 4, 2024) 
• 90-Day Supply Prescription Drug List (PDF)

Committees and meeting notices

• Drug Formulary Committee (DFC) webpage
• Drug Utilization Review (DUR) board webpage

Contact information

• Chad Hope, PharmD, Deputy Director, Health Care Purchasing and Service Delivery
• Mary Beth Reinke, Pharm.D., MSA, Drug Utilization Review Coordinator 
• Aaron Drake, RPh, VBC Program Lead Pharmacist
• Dave Hoang, PharmD, MBA, Clinical Pharmacist
• Sharon Rosenblum, PharmD, Drug Rebate Coordinator, 340B