Minnesota Department of Human Services / Minnesota …
MHCP Enrolled Providers
For drugs requiring prior authorization contact the new MHCP Prescription Drug PA Agent – 866-205-2818 (Phone) or 866-648-4574 (Fax)
Prescription Drug Information
• Preferred Drug List (PDF)
• MHCP OTC Formulary (PDF) and MHCP OTC Formulary (XLS)
• PA Criteria and Regimen Review Sheets
• All drugs requiring prior authorization
• Drugs requiring a diagnosis code
• Fee for Service Medicaid Excluded Drugs
• Medical Supply Related Lists
July 2008 NCPDP Letter to Medicaid with information about Tamper-Resistant Prescription Blanks
Prior Authorization Forms and Instructions
MHCP Drug Prior Authorization Form DHS-4424 (PDF)
MHCP Prescription Drug Reconsideration Request Form DHS-4667 (PDF)
Hepatitis C Drug Prior Authorization DHS-7085 (PDF)
Immunomodulator Drug Authorization Form DHS-5212 (PDF)
MHCP Clinic Tool for the Assessment and Management of Persistent Pain DHS-6109 (PDF)
Opioids: High Dose Opioid Drug Authorization Form DHS-7072 (PDF)
MHCP Psychiatric Consultation Request Form DHS-6176 (PDF)
MHCP 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)
Physician Administered Drugs
HCPCS Codes Requiring NDC
Additional Resources
MHCP Provider Manual - Authorization section
SMAC Research Request Form DHS-6406 (PDF)
Minnesota Medicaid Version D.0 NCPDP Payer Sheet (PDF)
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