Minnesota Health Care Programs and SeniorSelect

Formularies

Forms 

Prior authorization requests should be telephoned to ESI by calling 1-877-558-7523 or filling out the appropriate form(s) below and faxing it to them at 1-800-357-9577.

Prior Authorization form (For MHCP and SeniorSelect Only):
›  Prior Authorization Request Form

Quantity Limit Exception:
›  Quantity Override Request Form 

Non-Formulary Exception:
›  MN Uniform Formulary Exception Form