When a combined Medicare and Minnesota Health Care Programs prior authorization is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact Express Scripts’ Prior Authorization Department to answer criteria questions to determine coverage.
Please find below forms and information for these Medica health plans: Medica DUAL Solution and Medica AccessAbility Solution Enhanced.
HMO D-SNP Part D Coverage Determination Request Form (PDF)
Online Application to Submit a Coverage Determination Request
HMO D-SNP Part D Coverage Redetermination Request Form (PDF)
Online Application to Submit a Redetermination Request
HMO D-SNP Part D Prior Authorization Formulary Criteria (PDF)