MedicaidAdministrativeMedium impact
Single pharmacy benefit manager update
Minnesota Medicaid (MHCP)·MN · Pharmacy·Pharmacy
Effective date
Jan 1, 2028
We identified it
May 20, 2026
Summary
Minnesota Department of Human Services has contracted with Prime Therapeutics as the single pharmacy benefit manager (sPBM) to administer outpatient pharmacy benefits for Minnesota Health Care Programs members in managed care plans, effective January 1, 2028. Billing teams must prepare for a transition in how pharmacy claims are processed and routed for these plans, separate from the existing fee-for-service program.
Action Required
By September 2026: Billing team should monitor Minnesota DHS communications for detailed implementation timelines, billing instructions, and pharmacy claim submission requirements specific to Prime Therapeutics sPBM. By December 2027: Update billing software, encounter forms, and prior authorization workflows to route pharmacy claims for Minnesota Health Care Programs managed care members to Prime Therapeutics instead of current vendors. Attend provider training sessions when materials are released. Ensure staff understands that Prime Therapeutics sPBM processes are separate from the existing fee-for-service pharmacy claims process. Failure to route claims correctly will result in claim denials or delays for affected members.