Pharmacy

Prior Authorization Forms Claim Jumper Newsletters

General Information for Providers  
Medicaid manual with general information for all provider types.

Prescription Drug Program 
This manual has information specific to your provider type.

Preferred Drug List 03/05/2024

List of preferred drugs and other preferred drug list information.

Montana Healthcare Programs cover the following non-prescriptions (OTC) medications manufactured by companies who have signed a federal rebate agreement.

*Nursing facilities are responsible for providing OTC antacids, aspirin, and laxatives to their residents.
  • Antacids*
  • Aspirin*
  • Diphenhydramine
  • Doxylamine
  • Folic acid
  • H2 antagonist GI products
  • Head lice treatment
  • Insulin
  • Ketotifen ophthalmic solution
  • Laxatives*
  • Levonorgestrel
  • Nonsedating antihistamines (as listed on PDL)
  • Nicotine patches, gum and lozenges
  • Oxybutynin transdermal
  • Proton pump inhibitors (as listed on PDL)
  • Pyridoxine
  • Steroid nasal spray
Also, Montana Healthcare Programs may cover select vitamins and minerals, regardless of rebate. Criteria may apply.

2024

03/27/2024 HHS Letter to Healthcare Providers
03/27/2024 Resources for Providers in Response to the Change Healthcare Cyberattack
03/27/2024 Updated CLIA Claims Editing
03/27/2024 Avoiding Claim Denials
03/27/2024 Location Address and Provider Maintenance Updates
03/19/2024 Electronic Funds Transfer Payment Verification
03/12/2024 Valid Member ID and Eligibility Verification
03/12/2024 Provider Initiated Claims Adjustment
03/05/2024 Voiding Claims With a Prior Authorization
01/23/2024 Montana Healthcare Programs Support Services Holiday Closure REVISED
01/17/2024 Prior Authorization Criteria for Atypical Antipsychotics for Children 8 Years of Age and Under REVISED
01/08/2024 AMP Cap Removal and Medication Access
01/08/2024 Electronic Claim Adjustment Processing Change 

2023

12/22/2023 Passport Provider Referral Number on Claims
12/12/2023 Individual Providers Enrolled as Sole Proprietors Due for Revalidation
11/07/2023 Pharmacy Provider License Renewal Reminder
11/01/2023 Beyfortus and Synagis Coverage for RSV Prophylaxis
10/31/2023 Managed Care Referrals IHS, Tribal 638, and Urban Indian Organizations REVISED
09/15/2023 Claims Payment Discrepancy Update
09/14/2023 Claims Payment Discrepancy Identified
09/08/2023 Medicaid Claims Payment Delayed
08/01/2023 Provider License Expiration Reminder Letters
07/06/2023 Provider Rate Increases
06/30/2023 2023 Annual Montana Dispensing Fee Survey
05/26/2023 Medicaid Reimbursement and Court Ordered Services REVISED
05/03/2023 End of PHE Pharmacy Signature Requirements
05/03/2023 Makena PV Makena (Hydroxyprogesterone Caproate Injection) Coverage
04/10/2023 Resumption of Face-to-Face Requirements for Selected Programs REVISED

03/22/2023 Coverage and Reimbursement Policy for Telemedicine/Telehealth Services
03/22/2023 End of Public Health Emergency (PHE) Effects on Pharmacy Coverage
03/22/2023 Non-Covered Services Agreement Policy Return to Requirements
03/22/2023 Reinstatement of the Primary Care Provider Referral for Passport
03/22/2023 Resumption of Face-to-Face Requirements for Selected Programs
03/22/2023 Resumption of Prior Authorization Requirements Revised 04/03/2023
03/17/2023 End of Temporary Revision to Case Management General Provisions
03/10/2023 Provider Meetings for Medicaid Eligibility Redetermination and Unwinding PHE Flexibilities
03/09/2023 Add-on and E&M Code Editing
03/03/2023 End of Public Health Emergency
01/31/2023 Omnipod Coverage
01/04/2023 Montana Healthcare Programs Support Services Holiday Closures

2022

12/23/2022 Plan First Updated Code List Descriptions
11/15/2022 Pharmacy Provider License Renewal Reminder
11/09/2022 
Prior Authorization Criteria for Synagis®
09/19/2022 New Plan First Covered Code
08/05/2022 Bipartisan Budget Act of 2018 Cost Avoidance Statute Changes
07/08/2022 2022 Annual Montana Dispensing Fee Survey
06/17/2022 Plan First Updated Code List Descriptions
05/31/2022 2022 Average Acquisition Cost (AAC) Survey
05/27/2022 Albuterol HFA Inhalers - Preferred Drug List Enforcement
05/16/2022 Help Members Receive Important Information from Montana Medicaid and Stay Covered
05/13/2022 Revalidation Extended REVISED
05/13/2022 National Drug Code (NDC) Denial Errors
04/26/2022 Health Behavior Assessment and Intervention Billing Codes REVISED
03/29/2022 Nurse First Advice Line Services Ending
03/16/2022 Revalidation Extended to June 2022 REVISED Rev. 05/13/2022
02/28/2022 COVID-19 At-Home Test Coverage
02/23/2022 Revalidation Extended to June 2022 Rev. 03/16/2022
02/23/2022 Standing Orders and Medicaid Reimbursement
02/08/2022 Vaccine Administration by Pharmacists
02/02/2022 Dose Limitations for Gabapentinoids
01/14/2022 Montana Healthcare Programs Support Services Holiday Closures

2021

12/20/2021 Plan First Updated Code List Descriptions
12/15/2021 Health Behavior Assessment and Intervention Billing Codes Rev. 04/26/2022
12/10/2021 New Provider Services Portal
11/05/2021 Pharmacy Provider License Renewal Reminder
09/24/2021 Codes Removed from and Added to Plan First Covered Code List
09/23/2021 Prior Authorization Criteria for Synagis®
09/16/2021 Billing Update - Licensed Marriage and Family Therapist (LMFT)
07/20/2021 Enrollment Update – Licensed Marriage and Family Therapist
07/09/2021 2021 Annual Montana Dispensing Fee Survey
07/06/2021 Adoption Of Temporary Emergency Rule To Allow for COVID-19-Related
Regulatory Discretion Beyond The Expiration Of The Governor-Declared State Of Emergency
06/11/2021 COVID-19 Vaccine Administration Billing Guidance
05/12/2021 2021 Average Acquisition Cost (AAC) Survey
04/26/2021 Billing for COVID-19 Vaccine
04/08/2021 Electronic Prior Authorization Process for Suboxone® Films for Medication Assisted Therapy
04/02/2021 
New Provider Type – Licensed Marriage and Family Therapist
02/11/2021 Billing for COVID-19 Vaccine
01/28/2021 Montana Healthcare Programs Support Services Holiday Closures
01/21/2021 Montana Plan First Additional Codes Added to Plan First Covered Code List
01/11/2021 Provider Support Services Closed for Martin Luther King Day, Monday, January 18, 2021

2020

12/07/2020 Medicaid Expansion Extended Through December 31, 2021 
12/01/2020 Change in Application Process for Plan First
11/12/2020 Removal of Codes for COVID-19 Testing and Treatment
11/10/2020 Prior Authorization Criteria for Synagis®
10/28/2020 Provider Relief Fund General Allocation
10/15/2020 Pharmacy Provider License Renewal Reminder
10/08/2020 Montana Plan First - Addition of Radiologic Examination Codes for Abdomen; 1, 2, and 3 Views
08/28/2020 Provider Relief Fund General Allocation rev. 08/28/2020

08/11/2020 Provider Relief Fund General Allocation rev. 08/11/2020

07/27/2020 Montana Plan First - Additional Covered Code, COVID - Testing
07/24/2020 Provider Relief Fund General Allocation

07/17/2020 Medicaid Reimbursement and Court Ordered Services
07/02/2020 New Required NCPDP Field
06/26/2020 Vaccine Administration by Pharmacists
06/17/2020 National Correct Coding Initiative Announcement
05/15/2020 Temporary Revision to Case Management General Provisions
04/30/2020 National Correct Coding Initiative Announcement
04/28/2020 Temporary Suspension of the PCP Referral Requirement
04/27/2020 Non-Covered Services Agreement Policy Change

04/22/2020 Suspension of Prior Authorizations or Continued Stay Reviews and Clinical Requirements for Some Medicaid Programs

04/06/2020 2020 Annual Montana Dispensing Fee Survey rev. 04/15/2020
04/06/2020 2020 Average Acquisition Cost (AAC) Survey
04/01/2020 Suspension of Face to Face Requirements for Some Medicaid Programs
03/26/2020 Montana Plan First - Additional Covered Codes, Telemedicine/Telehealth
03/20/2020 Billing for Insulin Products 
03/19/2020 Telemedicine Medicaid Coverage and Reimbursement Policy for Telemedicine/Telehealth  rev 03/27/2020

02/28/2020 Starting Dose and Quantity Limitations for Sedative Hypnotics
01/10/2020 Co-Payment Assessed in Error for January 6, 2020

01/03/2020 Changes to Hepatitis C Treatment Criteria

Montana Drug Use Review (DUR) Board / Formulary Committee
Notification of upcoming meetings for drug use review, agendas, related meeting information, and minutes from past meetings.

Drug Use Review Board
Information on the Medicaid Drug Use Review Board.

MHSP Formulary 08/31/2015 (Reviewed 04/06/2022)