Department of Public Health and Human Services

Montana Healthcare Programs Provider Information » menutest » TestPage

Main Content

TestPage

Text/HTML

Live Accordion

Physician Administered Drugs

Instructions for Physician Administered Drug Prior Authorization:

  1. Please check posted criteria before submitting a prior authorization request (see links below). Make sure preferred drugs have been tried first and that there is documentation supporting this.
  2. Complete Physician Administered Drug Prior Authorization Form found at https://medicaidprovider.mt.gov/forms.
  3. Fax completed form to (406) 444-1861, attention to the appropriate Program checked on the form. Make sure to include complete contact information and where the drug will be administered.

Reminders: 

  • Montana Medicaid does not reimburse for convenience, off label or experimental use of drugs, per Administrative Rules of Montana (ARM) 37.85.207. 
  • In general, drugs billed with unlisted codes require prior authorization from the State.
  • NDC must be rebateable.

Drugs with specific criteria sets:

Cinquair®
Krystexxa®
Lucentis®
Nucala®
Ocrevus®
Prolia®
Spinraza®
Supprelin®
Xgeva®