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Pharmacy

Pharmacy

Provider Manuals

General Information for Providers 02/2017

Medicaid manual with general information for all provider types.

Prescription Drug Program 12/2016

This manual has information specific to your provider type.

Provider Manuals – Replacement Pages

General Information for Providers

02/06/2017

In summary, the Telemedicine Chapter was added as a new chapter.  And the Medically Needy section of the Member Responsibilities Chapter page 6.5 was updated.

08.02.2016

07.12.2016

General Information For Providers, July 2016

01.19.2016

General Information for Providers, January 2016: Introduction Regarding HELP Plan Information

01.15.2016

General Information for Providers, January 2016: Introduction Regarding HELP Plan Information

12.31.2015

General Information for Providers, January 2016: HELP Plan-Related Updates and Others

11.17.2015

General Information for Providers, November 2015: Billing Procedures, Revenue Codes 25X and 27X

07.31.2015

General Information for Providers, August 2015: Entire Manual

11.19.2014

General Information for Providers, November 2014: Billing Procedures

10.08.2014

General Information for Providers, September 2014: Billing Procedures

07.22.2014

General Information for Providers, June 2014: Member Eligibility and Responsibilities, Presumptive Eligibility

06.30.2014

General Information for Providers, June 2014: Entire Manual
If information is found on the website, it has been removed from the manual, and a link to the source is provided.

04.13.2012

General Information for Providers: Medicaid Covered Services and Client Eligibility

Prescription Drug Program

12/27/2016

In summary, the Cost Share section of the Billing Procedures chapter was updated and the Cover Page was updated with the current date.

11/15/2015

In summary, the Reimbursement Chapter has some revised language changes, the whole Prescription Drug Manual has been reformatted with changes approved for all manuals in September 2016, and the Cover page was updated with the most recent modification date

06.27.2016

Prescription Drug Program, July 2016: In summary, the Reimbursement for Covered Drugs and FMAC were modified, Average Acquisition Cost and Submitted Ingredient Cost sections were added, and the Estimated Acquisition Cost section was removed from Chapter 6, Reimbursement. The Table of Contents was updated and the Cover Page was amended to reflect the effective date.

06.15.2016

Prescription Drug Program, July 2016: Cost Share Updates

12.31.2015

Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others

07.21.2015

Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures

03.25.2015

Prescription Drug Program, Entire Manual

09.27.2013

Prescription Drug Program, Reimbursement

09.05.2013

Prescription Drug Program, Entire Manual Including the New Passport Chapter
This set of replacement pages contains a terminology change ("client" to "member"); however, only content changes are marked with a change bar (black line).

04.17.2013

Prescription Drug Program, Key Contacts and Reimbursement

02.04.2013

Prescription Drug Program, Medicaid Covered Products

02.01.2012

Prescription Drug Program, Multiple Chapters

09.01.2011

Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)

06.17.2011

Prescription Drug Program
Entire manual has changed from last posted version.

11.16.2004

Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria

06.16.2004

Prescription Drug Program, Prior Authorization and HIPAA Updates

06.10.2004

Prior Authorization Additions

Preferred Drug Information

Preferred Drug List 03/23/2017

List of preferred drugs and other preferred drug list information.

Evidence-Based Medicine Documentation

Resources used by the Montana Formulary Committee members come from the OHSU Drug Effectiveness Review Project which can be accessed through this link.

Average Acquisition Cost Links

Provider Notices 2010–

2017


05/15/2017  2017 Average Acquisition Cost (AAC) Survey
05/09/2017  2017 Annual Montana Dispensing Fee Survey
04/20/2017  Plan First Hysterectomy codes added effective April 1, 2017
04/11/2017  Medication Authorization Changes
04/06/2017 New EPSDT Request Form
03/31/2017  Ketone Test Strips - A4250 & A252

2016

11/30/2016 EnLyte®
11/21/2016 Humira Unit Submission
11/21/2016 PA for Methadone
11/03/2016 Smart PA® for Synagis® Revised 11/15/2016
09/26/2016 Coverage of Weighted Blankets
08.12.2016 Vaccine Administration by Pharmacists
08.12.2016 Removal of 15-day Supply Limit on Initial Atypical Antipsychotic Prescriptions
07.28.2016 Montana Plan First Preventive Code Additions
07.18.2016 Changes to Member Cost Share Update
06.27.2016 Reverse and Rebill for Drug Cost Disputes
06.27.2016 Average Acquisition Cost Reimbursement Methodology
05.19.2016 Changes to Member Cost Share
04.06.2016 Hepatitis C Prior Authorization Streamlined Request Form
03.04.2016 Vaccine Administration by Pharmacists for Adolescents Age 12-18 Years
02.01.2016 Basic Medicaid Benefit Increased to Standard Medicaid Benefit
01.15.2016 Standard Medicaid and HELP Plan Claims Processing Rev. 01.19.2016
01.15.2016 Hospital Grade Electric Breast Pump Requirements

2015

12.31.2015 Changes to Montana Medicaid
12.31.2015 Montana HELP Plan
11.30.2015 New Montana Medicaid Pharmacy Claims Processing System
11.13.2015 Oral Nutrition for Children Under Age 21 – EPSDT
11.03.2015 Pharmacy Provider License Status
11.03.2015 Services Exempt from Passport to Health Referral
10.21.2015 SmartPA® Prior Authorization for Synagis®
10.09.2015 Plan First Prescriptions and ICD-10
10.09.2015 Montana Plan First – ICD-10 Update
10.01.2015 Changes to the Children's Mental Health Bureau Medicaid Services Provider Manual
09.25.2015 2015 Annual Montana Dispensing Fee Survey
08.03.2015 ICD-10 Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10)
07.31.2015 Adult and Pediatric Specialty Table of Services Available in Montana
07.08.2015 Montana Plan First – Revised List of Plan First Covered Services
06.09.2015 National Drug Code (NDC) Billing
05.07.2015 Anesthesia and Global Service Requirement
05.06.2015 Prior Authorization Required for Jublia® Topical Solution
03.27.2015 Initial Prescription Fill Requirements for Attention Deficit Hyperactive Disorder Stimulant Drugs
02.23.2015 New Restrictions Added to Hydrocodone-Chlorpheniramine Suspension (Tussionex®)
02.11.2015 New HCPCS Modifiers – XE, XP, XS, and XU

2014

12.18.2014 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Changes Final Notice
11.24.2014 Pharmacy Provider License Status
11.24.2014 DME Order and Prescription Requirements
10.27.2014 Prior Authorization Criteria for Hepatitis C Treatments
  All PA forms for Hepatitis C Treatments are now in the Forms section of the website as of 03.21.2016
10.20.2014 SmartPA® Prior Authorization for Synagis®
10.01.2014 Prior Authorization Required for the Antibiotic Sivextro® and the New Antifungal Luzu®
09.22.2014 Provider Atypical Anti Psychotics for Children Ages Six and Under – Prior Authorization Requirement
09.17.2014 2014 Annual Montana Dispensing Fee Survey
09.16.2014 Adoption of the New Children's Mental Health Bureau's Medicaid Provider Manual into Administrative Rules of Montana
08.22.2014 Tobacco Cessation Products
08.13.2014 Multisource Preferred Brand Name Products
08.05.2014 Montana Prescription Drug Registry
06.30.2014 Dispensing Fee Increase
06.12.2014 ICD-10 Delay
06.06.2014 SmartPA Quantity Limit for Oxycodone
05.13.2014 PERM Provider Educational Webinars
04.22.2014 Modifier Changes for Professional Claim Billers
03.18.2014 Information Regarding CMS-1500
01.29.2014 Centers for Medicare and Medicaid Services (CMS) ICD-10 Provider Readiness Assessment Update
01.28.2014 SmartPA® Prior Authorization for All Preparations to Treat Head Lice
01.28.2014 Prior Authorization for Zubsolv®
01.09.2014 Using Medicaid Card ID Number When Billing and Checking Eligibility
01.09.2014 Reimbursement Changes for Covered Ancillary Services Provided to Youth in a PRTF and Additional Information Pertaining to PRTF Services

2013

12.23.2013 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Changes Update
11.26.2013 ICD-10 Readiness
11.26.2013 Prior Authorization for Testosterone Products
09.30.2013 SmartPA® Prior Authorization for Synagis®
09.18.2013 Healthy Montana Kids (HMK) Pharmacy Benefit
09.11.2013 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Changes
09.09.2013 Updated Prior Authorization Request Form for Suboxone® and Subutex®
08.28.2013 Healthy Montana Kids Pharmacy Benefit
08.13.2013 Pharmacist Vaccine Administration for Adults Over 18 and Adolescents Between 12–18 Years of Age
07.01.2013 Dispensing Fee Increase and the Addition of a Vaccine Administration Fee
06.24.2013 2013 Annual Pharmacy Dispensing Fee Survey
06.20.2013 Montana Plan First – Additional Information
05.28.2013 DPHHS to Discontinue Temporary Hotline Number
05.13.2013 Montana Plan First – Revised List of Plan First Covered Services
03.14.2013 Vaccine Administration by Pharmacists for Adolescents Age 12–18 Years
02.19.2013 Montana Medicaid HIPAA Operating Rules Upgrade
02.11.2013 Montana Plan First Additional Information Updated

2012

12.26.2012 Medicaid/HMK Plus Toll-Free Number
12.20.2012 Prior Authorization Requirements for Namenda®, Natroba®, Sklice®, Rayos DR®, and Sorilux®
11.29.2012 Changes to the Medicare Part D Drug Benefit for Dual Eligible Clients – Benzodiazepines Effective 01.01.2013
10.17.2012 Smart PA® Prior Authorization for Synagis® and Montana Medicaid Synagis® Criteria 2012–2013
09.10.2012 Preferred Drug List (PDL) Expansion
08.22.2012 Deleted Eylea® ICD-9-CM-Codes
08.10.2012 Updated Plan First Billing Instructions
08.08.2012 Prior Authorization for Aflibercept Injection
07.30.2012 NPI Requirements for Pharmacy Claims Payment
07.30.2012 NCPDP D.0 Payer Sheet
07.13.2012 Dispense as Written (DAW) = 8 (Important Update)
06.13.2012 Plan First Billing Instructions
06.13.2012 NCPDP D.0 Payer Sheet Updated 06.11.2012
06.11.2012 Plan First Effective 06.01.2012
05.03.2012 Dispense as Written (DAW) = 9
05.03.2012 NCPDP D.0 Payer Sheet
03.08.2012 Vaccines for Children (VFC) Training
02.29.2012 NCPDP D.0 Submission Requirements
02.29.2012 Vaccine Administration by Pharmacists for Adolescents Age 12–18
02.29.2012 Coordination of Benefits Under NCPDP D.0
02.13.2012 New Medications under Prior Authorization and the Authorization Criteria Effective 02.06.2012

2011

12.30.2011 NCPDP D.0 Submission Requirements
12.09.2011 Medicare Part B Crossover Claims
12.08.2011 NCPCP D.0 Implementation
11.07.2011 Provider Information on HIPAA 5010 837 Health Care Claim Transactions
11.02.2011 Smart PA® and Prior Authorization for Synagis®
10.20.2011 Prior Authorization for Children's Vitamins
09.15.2011 NCPDP D.0 Submission Requirements
09.09.2011 HIPAA 5010.OCR Qualifier Changes Effective January 1, 2012
09.09.2011 DME Order and Prescription Requirements
09.07.2011 Payment Error Rate Measurement (PERM)
07.29.2011 NCPDP D.0 Submission Requirements
07.22.2011 Reduction of In-State Pharmacy Provider Dispensing Fees
07.18.2011 Reimbursement Changes for Covered Ancillary Services Provided to Youth in a PRTF and Additional Ancillary Services Are Covered
06.27.2011 HIPAA 5010.OCR Qualifier Changes Effective January 1, 2012
05.27.2011 Prior Authorization for Horizant®, Gralise®, Daliresp® and Sprix®
04.12.2011 Request: Claims Submission, Date of Payment by June 30, 2011
04.12.2011 Prior Authorization for Cycloset®
04.12.2011 Prior Authorization for Pradaxa®
04.12.2011 Prior Authorization for Nexiclon®
02.23.2011 Prior Authorization for Abstral®
01.05.2011 Prior Authorization for Kapvay®

2010

10.05.2010 Changes to NCCI Edits
07.28.2010 Provider Record Update Procedures
06.23.2010 Cost Sharing Exemption Under ARRA
06.22.2010 Electronic Health Records Link
02.25.2010 State Maximum Allowable Cost (SMAC)
02.09.2010 United States 2010 Census
02.08.2010 Medicaid Health Improvement Program
01.21.2010 Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers

Provider Notices 2002–2009

2009

12.17.2009 Updated Prior Authorization Request Form, Prior Authorization Request Update and Physician Chart Checklist for Suboxone or Subutex®
12.15.2009 Prior Authorization for Intuniv®
12.04.2009 Prior Authorization for Elidel® and Protopic®
12.04.2009 Prior Authorization for Embeda® 02.03.2010
12.04.2009 Prior Authorization for Nucynta®
11.24.2009 Provider Name and Phone Number Required Fields
10.01.2009 Healthy Montana Kids Plan
09.29.2009 Update: SmartPA® Prior Authorization for Synagis®
09.22.2009 NDC Billing Tools
09.10.2009 First DataBank, Medi-Span, and McKesson AWP Litigation Settlements: Pharmacy Reimbursements May Be Impacted by Upcoming Reporting Change
06.29.2009 Dispensing Fee Increase
05.19.2009 Latisse® (bimatoprost) Not Covered by Montana Medicaid
05.19.2009 Prior Authorization Requirements for Relistor®
05.19.2009 Prior Authorization Requirements for Provigil® and Nuvigil®
05.07.2009 Prior Authorization for Savella®
04.16.2009 Coordination of Benefits: Updated
04.14.2009 Prior Authorization Addition: Lidoderm®,Voltaren Gel®, Flector Patches® 04.21.2009
04.14.2009 Prior Authorization Addition: Uloric® 04.21.2009
04.14.2009 Prior Authorization for Ryzolt® 04.21.2009
04.10.2009 PRTF Three-Day Medication Supply
03.16.2009 Timely Filing for Medicare Crossovers
02.12.2009 Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers
01.12.2009 Change in Policy Regarding NCPDP Fields Dispense As Written (DAW) Product Selection Codes 5 and 7
01.12.2009 Refill Too Soon Edit Set to 90 Percent for Gabapentin

2008

10.20.2008 Changes in Transplant Coverage 10.27.2008
09.04.2008 SmartPA® Prior Authorization for Synagis®
09.04.2008 SmartPA® Prior Authorization for Marinol®
09.03.2008 SmartPA® Prior Authorization for Seroquel®
09.03.2008 Tamper-Resistant Rx Pad Update: Three Features Required October 1
09.03.2008 SmartPA® Maximum Daily Amounts for Acetaminophen
09.02.2008 Introducing SmartPA®
08.26.2008 Benefiber® Not Covered
08.12.2008 Federal Government May Request Medical Records 09.18.2008
07.14.2008 Delayed Payment for Pharmacy Providers
06.16.2008 Pharmacy Claims Pricing Adjustment
05.22.2008 Frequently Asked Questions About NPI Reenrollment and Billing 06.17.2008
05.21.2008 Maintenance Medications, Pharmacy Dispensing Fee Increase, and Signature Log Requirements
04.30.2008 New Suboxone® Criteria Sheet
04.10.2008 Billing Procedures Regarding National Drug Code (NDC) for Providers Using the CMS-1500 and 837-P
04.01.2008 Preferred Drug List (PDL): Brand Products No Longer Preferred Over Generics 05.12.2008
03.20.2008 Effexor XR® Dose Consolidation 04.22.2008
03.17.2008 Resubmission of Denied Claims 03.19.2008
03.11.2008 Billing Procedures Regarding National Drug Code (NDC) 10.15.2008
03.10.2008 NPI Reenrollment and Billing
02.29.2008 Prescription Origin Code Enabled
02.13.2008 Tamper-Resistant Prescription Pads
02.07.2008 NPI-Only Requirement for Pharmacies
01.28.2008 Sedative Hypnotic Coverage Changes (Ambien CR®, zolpidem, Rozerem®, Lunesta®, Sonata®
01.28.2008 Date of Birth on Pharmacy Claims – New Feature
01.18.2008 Possible Duplicate Claims Processed Through Electronic Data Interchange

2007

12.21.2007 Compound Prescription Billing Changes 01.16.2008
12.17.2007 Enhanced Claims Editing – Assistant, Team, Co-Surgeon
12.17.2007 Enhanced Claims Editing – Multiple Evaluation and Management Services Provided on the Same Day
12.04.2007 NPI Requirement for Fee-for-Service Healthcare Provider Claims
12.04.2007 Carisoprodol (Soma®) Containing Products to Require Prior Authorization
11.27.2007 Cost Share Changes
11.01.2007 Enhanced Claims Editing – Add-On Codes
11.01.2007 Enhanced Claims Editing – New Visit Evaluation and Management Codes
11.01.2007 Enhanced Claims Editing Bloodhound ClaimsGuard®
10.31.2007 Pharmacy 835 RA Problems
10.01.2007 Tamper-Resistant Prescription Pads – Postponed
09.20.2007 Tamper-Resistant Prescription Pads – Updated
08.17.2007 Zanaflex® Capsule
08.07.2007 Tamper-Resistant Prescription Pad Requirement
08.01.2007 Elimination of eSOR
06.25.2007 NPI on the Web Portal
06.11.2007 Ownership and Control Information Required for Reenrollment
06.06.2007 NPI Contingency Plan Implemented, Reenrollment Extended
05.31.2007 New CMS-1500 to Be Required Beginning July 2, 2007
05.22.2007 NPI Contingency Planning
04.19.2007 Abilify Dose Consolidation Updated from 11.2006
01.09.2007 Prior Authorization Addition

2006

08.30.2006 Extended Hours for Team Care Pharmacy Lock-in Suspensions
07.21.2006 Medicare Part B Crossover Changes 08.2011
06.12.2006 Prior Authorization for Ultram ER
05.05.2006 Refill Too Soon Edit Set to 90% for Controlled Substances (CII-CV) and Tramadol Products
03.20.2006 15-Day Supply Limit Clinical Edit on Initial Atypical Antipsychotic Prescriptions
03.13.2006 Prior Authorization for Suboxone®.Subutex®
02.08.2006 Prior Authorization Requirements for Rozerem® and Lunesta® Updated from 12.2005
01.13.2006 Erroneous Deductibles and High Copays With Medicare Part D

2005

12.02.2005 Coverage of Drugs for Sexual and Erectile Dysfunction Eliminated
10.04.2005 Pharmacy Audit Codes
07.28.2005 Scales – Congestive Heart Failure
05.11.2005 Pharmacy Reviews
04.07.2005 Heparin Flush Syringes – Coverage Issues
04.04.2005 Member Number Now a Billable Number
02.04.2005 Introduction to Preferred Drug List
02.02.2005 Prior Authorization Addition

2004

12.23.2004 NDC Deletions Effective January 1, 2005
06.15.2004 Coordination of Benefits Medicare Drug Discount Card and Medicaid Approved Other Coverage Code Valid Values
06.10.2004 Team Care Program A New Component of the Passport to Health Program
06.10.2004 Prescription Drug Prior Authorization Additions
01.29.2004 Prior Authorization Additions 02.2004
01.08.2004 Payment From Other Insurance Companies

 2003

12.31.2003 Important Update for NCPDP 5.1 Submitters
12.31.2003 Important Update for NCPDP 3.2 Submitters
12.01.2003 Billing Other Health Insurance Before Medicaid
11.25.2003 Prior Authorization Changes, Coverage of Loratadine, and Compound Prescriptions
10.16.2003 Prior Authorization Change
09.30.2003 NCPDP 5.1 Delayed Until October 16, 2003
09.05.2003 Verifying Eligibility With the Montana Access to Health Medicaid Hard Card
08.29.2003 Passport to Health Implementation in Prairie County
08.29.2003 DMEPOS Advisory Workgroup Openings
08.20.2003 Submitting HIPAA Compliant Claims – Information for All Providers
08.20.2003 Submitting HIPAA Compliant Claims – Information for Pharmacies
08.20.2003 New Pharmacy Manual and Program Changes
07.25.2003 MHSP Pharmacy Changes
03.01.2003 Pharmacy Prior Authorization and Refill Changes
01.29.2003 Prescription Drug Services Update
01.10.2003 New Provider Notification Procedure and Medicaid Changes
01.02.2003 Drug Prior Authorization Update
01.02.2003 Prior Authorization Replacement Pages

2002

10.01.2002 Billing for Medicare Crossovers After Medicare's 45-Day Response Time
09.01.2002 Cost Sharing Replacement Page
09.01.2002 Cost Sharing
08.01.2002 Cost Sharing Notice (Pharmacy)
07.01.2002 2.6% Reduction
06.20.2002 Passport to Health 24-Hour Availability
03.21.2002 Prior Authorization Reminders: DME, DMEPOS
02.14.2002 Weekly Payment Available
12.12.2002 Program (Pharmacy) Updates and Changes

Drug Use Review (DUR) Board

Montana Drug Use Review (DUR) Board / Formulary Committee 05.16.2016

Notification of upcoming meetings for drug use review, agendas, related meeting information, and minutes from past meetings.

Drug Use Review Board 10.2015

Information on the Medicaid Drug Use Review Board.

Medicaid Rules and Regulations

MHSP Information

08.31.2015 MHSP Formulary Rev.

08.27.2015 MHSP Preferred Manufacturers 07.2015

Other Resources

Dispensing Fee Questionnaire 09.2015

EOB R&R Crosswalk PDF and EOB R&R Crosswalk Excel 02.2011
With the implementation of HIPAA, Medicaid discontinued the use of Medicaid EOB codes and began using HIPAA standard reason and remark (R&R) codes. This document crosswalks the HIPAA standard R&R codes to the Medicaid EOB codes.

NCPDP D.0 Payer Sheet 07.2016

Plan First Medicaid Non-Covered Agreement 07.2012

Rebateable Manufacturers 04/2017

SURS Provider Self-Audit Protocol 10.2015

To locate older documents, access the Archive Page.