Pharmacy

Provider Manuals (Updated April 13, 2012)
Medicaid Rules/Regulations (Updated May 9, 2006)
Preferred Drug Information (Updated May 9, 2012)
Notices and Replacement Pages (Updated May 3, 2012)
Request for Information: Acquisition Costs (Updated April 8, 2008)
Other Resources (Updated May 3, 2012)
SMAC Information (Updated May 14, 2012)
MHSP Preferred Manufacturers (Updated December 9, 2011)
MHSP Formulary (Updated September 1, 2011)
Rebateable Manufacturers (Updated March 28, 2012)
Key Contacts (Updated April 13, 2012)

Provider Manuals
General Information for Providers Updated April 2012
Medicaid billing manual with general information for all provider types.
04/2012

Prescription Drug Program Updated December 2011
This manual has information specific to your provider type.
02/2012

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Medicaid Rules/Regulations
Administrative Rules of Montana (ARM)
Montana Code Annotated (MCA)
Code of Federal Regulations (CFR)

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Preferred Drug Information

Preferred Drug List
List of preferred drugs and other preferred drug list information
05/09/2012

Montana Drug Use Review Board / Formulary Committee Meetings
Notification of upcoming meetings for drug use review, and minutes from past meetings
05/08/2012

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.

Mental Health Preferred Drug List Workgroup Information
Link to agendas and minutes of workgroup meetings
02/2005

Drug Use Review Board
Information on the Medicaid Drug Use Review Board
07/2011

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Notices and Replacement Pages

05/03/12
Dispense as Written (DAW) = 9
NCPDP D.0 Payer Sheet Updated May 3, 2012

04/13/12
Replacement Pages; General Information for Providers Medicaid Covered Services and Client Eligibility

03/08/2012
Vaccines for Children (VFC) Training

02/29/2012
NCPDP D.0 Submission Requirements Important Update

02/29/2012
Vaccine Administration by Pharmacists for Adolescents Age 12–18 Important Update

02/29/2012
Coordination of Benefits Under NCPDP D.0

02/13/2012
New Medications under Prior Authorization and the Authorization Criteria Effective February 6, 2012

02/01/12
Replacement Pages, Prescription Drug Services
Multiple Pages

12/30/11
NCPDP D.0 Submission Requirements Important Update

12/09/11
Medicare Part B Crossover Claims Important Update

12/08/11
NCPCP D.0 Implementation Important Update

11/07/11
Provider Information on HIPAA 5010 837 Health Care Claim Transactions

11/02/11
Smart PA® Prior Authorization for Synagis®

10/20/11
Prior Authorization for Children's Vitamins

09/15/11
NCPDP D.0 Submission Requirements Important Update

09/09/11
HIPAA 5010/OCR Qualifier Changes Effective January 1, 2012

09/07/11
Payment Error Rate Measurement (PERM)

09/01/11
Replacement Pages Prescription Drug Services
Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)

07/29/11
NCPDP D.0 Submission Requirements

07/22/11
Reduction of In-State Pharmacy Provider Dispensing Fees

07/18/11
Reimbursement Changes for Covered Ancillary Services Provided to Youth in a Psychiatric Residential Treatment Facility (PRTF) and Additional Ancillary Services Are Covered

06/27/11
HIPAA 5010/OCR Qualifier Changes Effective January 1, 2012

06/17/11
Replacement Pages Prescription Drug Services (entire manual)

05/27/11
Prior Authorization for Horizant®, Gralise®, Daliresp® and Sprix®

04/12/11
Request: Claims Submission, Date of Payment by June 30, 2011

04/12/11
Prior Authorization for Cycloset®

04/12/11
Prior Authorization for Pradaxa®

04/12/11
Prior Authorization for Nexiclon®

02/23/11
Prior Authorization for Abstral®

01/05/11
Prior Authorization for Kapvay®

10/05/10
Changes to NCCI Edits

07/28/10
Provider Record Update Procedures Effective Immediately

06/23/10
Cost Sharing Exemption under ARRA

06/22/10
Electronic Health Records Link

02/25/10
State Maximum Allowable Cost (SMAC)

02/09/10
United States 2010 Census

02/08/10
Medicaid Health Improvement Program

01/21/10
Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers

12/17/09
Updated Prior Authorization Request Form, Prior Authorization Request Update and Physician Chart Checklist for Suboxone or Subutex®

12/15/09
Prior Authorization for Intuniv®

12/04/09
Prior Authorization for Elidel® and Protopic®

12/04/09
Prior Authorization for Embeda®
Updated February 3

12/04/09
Prior Authorization for Nucynta®

11/24/09
Provider Name and Phone Number Required Fields

10/01/09
Healthy Montana Kids Plan

09/29/09
Update: SmartPA® Prior Authorization for Synagis®

09/22/09
NDC Billing Tools

09/10/09
First DataBank, Medi-Span, and McKesson AWP Litigation
Settlements: Pharmacy Reimbursements May Be Impacted by Upcoming Reporting Change

06/29/09
Dispensing Fee Increase

05/19/09
Latisse® (bimatoprost) Not Covered by Montana Medicaid

05/19/09
Prior Authorization Requirements for Relistor®

05/19/09
Prior Authorization Requirements for Provigil and Nuvigil®

05/07/09
Prior Authorization for Savella®

04/16/09
Coordination of Benefits: Updated Updated April 17

04/14/09
Prior Authorization Addition: Lidoderm®,Voltaren Gel®, Flector Patches® Updated April 21

04/14/09
Prior Authorization Addition: Uloric® Updated April 21

04/14/09
Prior Authorization for Ryzolt® Updated April 21

04/10/09
PRTF Three-Day Medication Supply

03/16/09
Timely Filing for Medicare Crossovers

02/12/09
Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers

01/12/09
Change in Policy Regarding NCPDP Fields Dispense As Written (DAW) Product Selection Codes 5 and 7

01/12/09
Refill Too Soon Edit Set to 90 Percent for Gabapentin

10/20/08
Changes in Transplant Coverage Updated October 27

09/04/08
SmartPA® Prior Authorization for Synagis®

09/04/08
SmartPA® Prior Authorization for Marinol®

09/03/08
SmartPA® Prior Authorization for Seroquel®

09/03/08
Tamper-Resistant Rx Pad Update: Three Features Required October 1

09/03/08
SmartPA® Maximum Daily Amounts for Acetominophen

09/02/08
Introducing SmartPA®

08/26/08
Benefiber® Not Covered

08/12/08
Federal Government May Request Medical Records
Updated September 18

07/14/08
Delayed Payment for Pharmacy Providers

06/16/08
Pharmacy Claims Pricing Adjustment

05/22/08
Frequently Asked Questions About NPI Reenrollment and Billing - Updated June 17!

05/21/08
Maintenance Medications, Pharmacy Dispensing Fee Increase, and Signature Log Requirements

04/30/08
New Suboxone® Criteria Sheet

04/10/08
Billing Procedures Regarding National Drug Code (NDC) for Providers Using the CMS-1500 and 837-P

04/01/08
Preferred Drug List (PDL): Brand Products No Longer Preferred
Over Generics

03/20/08
Effexor XR® Dose Consolidation Updated April 22

03/17/08
Resubmission of Denied Claims Updated March 19

03/11/08
Billing Procedures Regarding National Drug Code (NDC) Updated October 15

03/10/08
NPI Reenrollment and Billing

02/29/08
Prescription Origin Code Enabled

02/13/08
Tamper-Resistant Prescription Pads

02/07/08
NPI-Only Requirement for Pharmacies

01/28/08
Sedative Hypnotic Coverage Changes (Ambien CR®, zolpidem, Rozerem®, Lunesta®, Sonata®

01/28/08
Date of Birth on Pharmacy Claims—New Feature

01/18/08
Possible Duplicate Claims Processed Through Electronic Data Interchange

12/21/07
Compound Prescription Billing Changes Updated January 16

12/17/07
Enhanced Claims Editing—Assistant / Team / Co-Surgeon

12/17/07
Enhanced Claims Editing—Multiple Evaluation and Management Services Provided on the Same Day

12/04/07
NPI Requirement for Fee-for-Service Healthcare Provider Claims

12/04/07
Carisoprodol (Soma®) Containing Products to Require Prior
Authorization

11/27/07
Cost Share Changes

11/01/07
Enhanced Claims Editing—Add-on Codes

11/01/07
Enhanced Claims Editing—New Visit Evaluation and Management Codes

11/01/07
Enhanced Claims Editing—Bloodhound ClaimsGuard®

10/31/07
Pharmacy 835 RA Problems

10/01/07
Tamper-Resistant Prescription Pads — Postponed

09/20/07
Tamper-Resistant Prescription Pads — Updated

08/17/07
Zanaflex® Capsule

08/07/07
Tamper-Resistant Prescription Pad Requirement

08/01/07
Elimination of ESOR

06/25/07
NPI on the Web Portal

06/11/07
Ownership and Control Information Required for Reenrollment

06/06/07
NPI Contingency Plan Implemented, Reenrollment Extended

05/31/07
New CMS-1500 to Be Required Beginning July 2, 2007

05/22/07
NPI Contingency Planning

04/19/07
Abilify Dose Consolidation Updated from November

01/09/07
Prior Authorization Addition

08/30/06
Extended Hours for Team Care Pharmacy Lock-in Suspensions

07/21/06
Medicare Part B Crossover Changes Updated August 2011

06/12/06
Prior Authorization for Ultram ER

05/05/06
Refill Too Soon Edit Set to 90% for Controlled Substances (CII-CV) and Tramadol Products

03/20/06
15-day Supply Limit Clinical Edit on Initial Atypical Antipsychotic Prescriptions

03/13/06
Prior Authorization for Suboxone®/Subutex®

02/08/2006
Prior Authorization Requirements for Rozerem® and Lunesta® Updated from December

01/13/06
Erroneous Deductibles and High Co-Pays With Medicare Part D

12/02/05
Coverage of Drugs for Sexual and Erectile Dysfunction Eliminated

10/04/05
Pharmacy Audit Codes

07/28/05
Scales - Congestive Heart Failure

05/11/05
Pharmacy Reviews

04/29/05
General Manual Replacement Page - Member Number a Billable Number and Key Contacts Updated

04/07/05
Heparin Flush Syringes - Coverage Issues

04/04/05
Member Number Now a Billable Number

02/04/05
Introduction to Preferred Drug List

02/02/05
Prior Authorization Addition

12/23/04
NDC Deletions Effective January 1, 2005

11/16/04
Pharmacy Manual Replacement Pages - Updated Prescription Drug PA Criteria

11/05/04
General Manual Replacement Pages - References to Medicaid Rules/Regulations Added

09/16/04
General Manual Replacement Pages - Team Care and Nurse First Information Added

06/16/04
Prescription Drug Manual Replacement Pages - PA and HIPAA Updates

06/15/04
Coordination of Benefits - Medicare Drug Discount Card and Medicaid Approved Other Coverage Code Valid Values

06/10/04
Team Care Program - A New Component of the Passport to Health Program

06/10/04
Prior Authorization Additions

01/29/04
Prior Authorization Additions Updated 02/04

01/08/04
Payment From Other Insurance Companies

12/31/03
Important Update for NCPDP 5.1 Submitters

12/31/03
Important Update for NCPDP 3.2 Submitters

12/01/03
Billing Other Health Insurance Before Medicaid

11/25/03
Prior Authorization Changes, Coverage of Loratadine, and Compound Prescriptions

10/16/03
Prior Authorization Change

09/30/03
NCPDP 5.1 Delayed Until October 16, 2003

09/05/03
Verifying Eligibility With the Montana Access to Health Medicaid Hard Card

08/29/03
Passport to Health Implementation in Prairie County

08/29/03
DMEOPS Advisory Workgroup Openings

08/20/03
Submitting HIPAA Compliant Claims - Information for All Providers

08/20/03
Submitting HIPAA Compliant Claims - Information for Pharmacies

08/20/03
New Pharmacy Manual and Program Changes

07/25/03
MHSP Pharmacy Changes

03/01/03
Pharmacy Prior Authorization and Refill Changes

01/29/03
Prescription Drug Update

01/10/03
New Provider Notification Procedure and Medicaid Changes

01/02/03
Drug Prior Authorization Changes

01/02/03
Prior Authorization Replacement Pages

10/01/02
Billing for Medicare Crossovers After Medicare's 45 Day Response Time

09/01/02
Cost Sharing Replacement Page

09/01/02
Cost Sharing

08/01/02
Cost Sharing Notice (Pharmacy)

07/01/02
2.6% Reduction

06/20/02
Passport to Health 24-Hour Availability

03/21/02
Prior Authorization Reminders: DME, DMEOPS

02/14/02
Weekly Payment Available

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Request for Information: Acquisition Costs
Department Request
04/08/08

Drug Cost Spreadsheet
04/08/08

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Other Resources
NCPDP D.0 Payer Sheet
05/2012

Drugs Requiring Prior Authorization
12/30/2011

NCPDP 5.1 Payer Sheet
Payer sheet for point-of-sale claims
04/2011

EOB R&R Crosswalk in PDF Format
EOB R&R Crosswalk in Excel Format
With the implementation of HIPAA, Medicaid will discontinue the use of Medicaid EOB codes and begin using HIPAA standard reason and remark (R&R) codes. This document crosswalks the HIPAA standard R&R codes to the Medicaid EOB codes.
02/2011

Most Commonly Used NDCs
12/2009

Cost to Dispense Survey
06/2009

List of Bulk Powders for Compound Medications—Rebateable as of 08/27/2008
08/2008

Tamper-Resistant Prescription Pads
CMS guidance and FAQs on tamper-resistant prescription pad laws
09/2007

Tamper-Resistant Prescription Pad Vendors
11/2011

Self Audit Policy and Procedure
04/2009

Carrier ID List
TPL insurance carriers listed by carrier ID
05/2012
Carrier ID List
TPL insurance carriers listed by name
05/2012

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SMAC Information
Montana SMAC List
05/14/2012

SMAC Pricing Inquiry Worksheet
02/2010

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Key Contacts
Pharmacy
10/2011

Claims
03/2012

Public Assistance Offices
03/2012

Client Eligibility
04/2012

HMK/CHIP
12/2010

Passport
03/2012

Policy Information
03/2012

Prior Authorization
03/2012

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