Pharmacy prior authorization and other resources

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

For drugs requiring prior authorization (PA), contact the Minnesota Health Care Programs (MHCP) prescription drug PA agent at 866-205-2818 (phone) or 866-648-4574 (fax).

Prior authorization forms and instructions

• Drug Prior Authorization Form (DHS-4424) (PDF)
• Prescription Drug Reconsideration Request Form (DHS-4667) (PDF)
• MHCP Authorization Form (DHS-4695) (PDF)
• Hepatitis C Drug Prior Authorization (DHS-7085) (PDF)
• Immunomodulator Drug Authorization Form (DHS-5212) (PDF)
• Clinic Tool for the Assessment and Management of Persistent Pain (DHS-6109) (PDF)
• High Dose Opioid Drug Authorization (DHS-7072) (PDF)
• Synagis Authorization Form (DHS-6428) (PDF)
• Advance Recipient Notice of Non-covered Service/Item (DHS-3640) (PDF)
• Advance Recipient Notice of Non-covered Prescription (DHS-3641) (PDF)

Additional resources

• 90-day supply prescription drug list
• HCPCS codes requiring NDC
• State MAC List (PDF) Updated frequently
• State MAC Specialty Drug List (PDF) Updated frequently
• SMAC Research Request Form (DHS-6406) (PDF)
• Minnesota Medicaid Version D.0 NCPDP Payer Sheet (DHS-7616) (PDF) (current through Nov. 3, 2024)
• Minnesota Health Care Programs Pharmacy Modernization Module NCPDP D.0 Payer Specifications Claim Billing (PDF) (effective Nov. 4, 2024)
• Minnesota's opioid prescribing guidelines

Committees and meeting notices

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

Contact information

• Senior LinkAge Line: 800-333-2433
• Disability Hub MN (formerly Disability Linkage Line): 866-333-2466
• 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