Instructions for Physician Administered Drug Prior Authorization:
- 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.
- Complete Physician Administered Drug Prior Authorization Form found at https://medicaidprovider.mt.gov/forms.
- 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.
- 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: