Pharmacy Info

• Comprehensive Formulary (.pdf) for AbilityCare WITH Medicare & SeniorCare Complete
  • For other program formularies, see individual program pages.
• SCHA Pharmacy BIN and PCN (.pdf)
• Limited Income Newly Eligible Transition Program (.pdf)
• Zostavax (shingles) Vaccine Billing Process (.pdf)
• New! Zostavax (shingles) Claim form (.pdf)

Medicaid Pharmacy Forms

• Medicaid Formulary Exception Prior Authorization (pdf)
• Medicaid Quantity Limit Exception Form (pdf)

Medicare Pharmacy Forms

• AbilityCare Pharmacy Forms (MyPrime.com)
• SeniorCare Complete (MyPrime.com)

Last Updated: 1-20-12
H5703_1747, H2419_1747, CMS Approved 7-31-2011
H2419_1736, H5703_1736, CMS Approved 7-30-2011
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South Country Health Alliance is a Coordinated Care plan with a Medicare Advantage
contract and a contract with the Minnesota Medical Assistance program.