Families and Children

Jump To...

• Program Description
• Enrollment/Eligibility
• Benefits
• Providers and Pharmacies
• Prescription Drug Benefits
• Cost Sharing (copays/deductibles/premiums)
• Appeals and Grievances (complaints)
• Member Outreach
• Contact Us
• Secure Member Site
• Language Resources and Accessibility

Questions? Need help? Call Member Services! All calls during business hours are answered by a person, not a machine. We're here to help you. You can also go to the PrimeWest Health Secure Member Site to get more information about your services, to contact us, or to ask for print copies of your member materials.

Program Description

Families and Children provides health care and prescription drug coverage for pregnant people, children under age 21, and adults under age 65 who have Medical Assistance. People apply for Medical Assistance through their county Social/Human/Family/Tribal services office or at www.MNsure.org.

To get the most up-to-date information about the Medical Assistance program, go to the Minnesota Department of Human Services (DHS) website.

Enrollment/Eligibility

To apply for Medical Assistance coverage, contact the county you live in or the Tribal office or apply online at www.MNsure.org. If you are eligible for Medical Assistance, you will be able to enroll in PrimeWest Health Families and Children for your covered services if you live in our service area. Our Families and Children service area includes the following counties: Beltrami, Big Stone, Chippewa, Clearwater, Cottonwood, Douglas, Grant, Hubbard, Jackson, Kandiyohi, Lac qui Parle, Lincoln, Lyon, McLeod, Meeker, Nobles, Pipestone, Pope, Redwood, Renville, Stevens, Swift, Traverse, and Yellow Medicine.

Benefits

To learn about the benefits and coverage provided by Families and Children, read the Member Handbook. It gives details about the health care services we cover. It tells how to get your health care as a PrimeWest Health Families and Children member. It also explains the rights, benefits, and responsibilities of members.

Organization Determinations
PrimeWest Health has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called “coverage decisions” in the Member Handbook. Standard organization determinations are made as quickly as the member’s health condition requires and not more than 5 business days from the date we get the request. Expedited organization determinations are made as quickly as the member’s health condition requires and not more than 48 hours (including 1 business day) from the date we get the request. Expedited organization determinations are for cases where the provider or PrimeWest Health decides that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function. You can ask for an organization determination in any of the following ways:

1. By Phone
   If you call us, we will need to get more information from your health care provider. Start by calling Member Services.
2. By Mail or Fax
   You and your health care provider can print and fax or mail the Medical Service Authorization Request Form. Your provider can download the form from the Service Authorization Forms page of our website or they can submit it electronically via the PrimeWest Health Provider Web Portal. The form should be sent to:
   
   Mail: PrimeWest Health Service Authorization
            3905 Dakota St
            Alexandria, MN 56308
   
   Fax: 1-866-431-0804
3. Online
   You and your health care provider can complete an online Service Authorization request. Your provider can access the form from the Service Authorization Forms page of our website.

Providers and Pharmacies

• Read the Provider and Pharmacy Directory to find a full list of health care providers (including specialists) in the PrimeWest Health network.
• Use our online search feature to find out if a specific provider is in the PrimeWest Health network.
• Use our online search feature to find out if a specific pharmacy is in the PrimeWest Health network.

Prescription Drug Benefits

Drug Coverage

• To find out if specific prescription drugs are covered by PrimeWest Health Families and Children, read the List of Covered Drugs or use our online search feature. Our formulary is updated throughout the year. Refer to Formulary Updates for the most recent changes. Note: If you have other insurance coverage, contact that insurance plan for information about its drug coverage. If you have Medicare, you must enroll in a Medicare Prescription Drug Plan (Part D) to get most of your prescription drug services. PrimeWest Health will not pay for any Part D eligible or excluded drugs when you have Medicare through another plan.
• To find out if your drug is considered a specialty drug, refer to our Specialty Drug List. You must use MedImpact Direct Specialty network to fill specialty drug prescriptions. If you or your provider have questions, call 1-877-391-1103 (TTY 711). The call is free.
• To find out if any of your over-the-counter drugs are covered by PrimeWest Health Families and Children, use our online search feature. The items included there are covered when you have a prescription from your health care provider or pharmacist.
• If the drug you are taking is not on our List of Covered Drugs, read the Member Handbook to find out what you can do. This includes instructions for both new and current members.
• If you want help managing your prescription drugs, read about our Medication Therapy Management Program and its eligibility requirements.

Restrictions on covered drugs 
Some drugs have restrictions on coverage. The restrictions are called Utilization Management (UM) programs. UM programs include Prior Authorization, Quantity Limits, and Age Requirements. Read more about our UM programs in the List of Covered Drugs.

You may ask for an exception to the drug coverage and restriction rules by using the Formulary Exception Form. Note: This form must be completed by a health care provider. You can also submit an online Formulary Exception.

Cost Sharing (copays/deductibles/premiums)

Cost sharing refers to your responsibility to pay an amount towards your medical or pharmacy costs. You do not have any copays for medical or pharmacy benefits. For more information, read the Member Handbook or call Member Services.

Appeals and Grievances (complaints)

If you disagree with a decision or have a complaint about your health care, services, or coverage, you may file a Grievance (complaint) or Appeal. You may use the online PrimeWest Health Member Appeal and Grievance Form to submit your Grievance or health plan Appeal. If you do not agree with the outcome of your health plan Appeal, you can request a State Appeal (Fair Hearing with the State). Read more about the processes for doing any of these things in the Member Handbook.

Member Outreach

Interested in getting involved? Do you have feedback that could help improve our plans? Then we want to hear from you! PrimeWest Health hosts regular stakeholder meetings. These meetings give members and their advocates and providers a chance to learn about their benefits and how to navigate the health care system. They also let members, advocates, and providers share their ideas, opinions, concerns, and suggestions about the services offered by PrimeWest Health. This stakeholders’ group has helped PrimeWest Health identify and put in place changes to provide better service to our members. We have 2 stakeholder meetings each year, as follows:

• 3rd Wednesday of April at 3 p.m.
• 3rd Wednesday of September at 3 p.m.

Meetings are held at PrimeWest Health’s office in Alexandria, MN, and other locations throughout our service area. A remote call-in option is also available. Interpreter services and auxiliary aids are available for each meeting. If you're interested in joining, call Member Services! You can also ask for minutes from previous stakeholders’ meetings if you want to learn more.

Contact Us

Secure Member Site

Log in to the PrimeWest Health Secure Member Site to view your benefits and member information. Once logged in, you can do the following:

• Ask for a new member ID card
• Update your member information
• Complete a Health Risk Assessment and use online tools to keep you healthy
• Ask to have Population Health Management or Care Management services
• Ask questions
• Ask for materials
• View services that need authorization
• View eligibility and claims status
• Find information about drug copays, generic drug substitutes, and pharmacy locations
• File an Appeal or Grievance

PW_06-25_117
DHS_Approved_12/05/2025
Updated_01/01/2026