Pharmacy
Provider Manuals
General Information for Providers
Medicaid billing manual with general information for all provider types. (04/2012)
Prescription Drug Program
This manual has information specific to your provider type. (04/2013)
Medicaid Rules/Regulations
Code
of Federal Regulations (Title 42)
Montana Code Annotated (Title 53, Chapter 6)
Administrative
Rules of Montana (Title 37)
- Chapter 79 Healthy Montana Kids
- Chapter 82 Medicaid Eligibility
- Chapter 83 Medicaid for Certain Medicare Beneficiaries and Others
- Chapter 85 General Medicaid Services
- Chapter 86 Medicaid Primary Care Services
MHSP Information
- 09/01/2011 MHSP Formulary
- 04/17/2013 MHSP Preferred Manufacturers
Preferred Drug Information
Preferred
Drug Information (04/25/2013)
- Preferred
Drug List (04/25/2013)
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. - Mental
Health Preferred Drug List Workgroup Information (02/2005)
Link to agendas and minutes of workgroup meetings.
Drug Use Review (DUR) (04/25/2013)
- Montana
DUR Board / Formulary Committee (04/25/2013)
Notification of upcoming meetings for drug use review, agendas, and minutes from past meetings. - Drug
Use Review Board (07/2012)
Information on the Medicaid Drug Use Review Board.
SMAC Information (05/07/2013)
- Montana SMAC List (05/07/2013)
- SMAC Pricing Inquiry Worksheet (02/2010)
Provider Notices and Provider Manual Replacement Pages
Provider Notices (05/13/2013)
2013
- 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 Update
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 (06/11/2012)
- 06/11/2012 Plan First Effective June 1
- 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 (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 02/06/2012)
2011
- 12/30/2011 NCPDP D.0 Submission Requirements (Important Update)
- 12/09/2011 Medicare Part B Crossover Claims (Important Update)
- 12/08/2011 NCPCP D.0 Implementation (Important Update)
- 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 (Important Update)
- 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
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® Updated 04/21/2009
- 04/14/2009 Prior Authorization Addition: Uloric® Updated 04/21/2009
- 04/14/2009 Prior Authorization for Ryzolt® Updated 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 Updated 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 Acetominophen
- 09/02/2008 Introducing SmartPA®
- 08/26/2008 Benefiber® Not Covered
- 08/12/2008 Federal Government May Request Medical Records Updated 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 Updated 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 Updated 05/12/2008
- 03/20/2008 Effexor XR® Dose Consolidation Updated 04/22/2008
- 03/17/2008 Resubmission of Denied Claims Updated 03/19/2008
- 03/11/2008 Billing Procedures Regarding National Drug Code (NDC) Updated 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 Updated 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 Updated 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 Prior Authorization Additions
- 01/29/2004 Prior Authorization Additions Updated 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 DMEOPS 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 Update
- 01/10/2003 New Provider Notification Procedure and Medicaid Changes
- 01/02/2003 Drug Prior Authorization Changes
- 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, DMEOPS
- 02/14/2002 Weekly Payment Available
Provider Manual Replacement
Pages (04/17/2013)
General Information for Providers
- 04/13/2012 Medicaid Covered Services and Client Eligibility
- 04/29/2005 Member Number a Billable Number and Key Contacts Updated
- 11/05/2004 References to Medicaid Rules/Regulations Added
- 09/16/2004 Team Care and Nurse First Information Added
Prescription Drug Program
- 04/17/2013 Key Contacts and Reimbursement
- 02/04/2013 Medicaid Covered Products
- 02/01/2012 Multiple Chapters
- 09/01/2011 Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)
- 06/17/2011 Prescription Drug Services (entire manual)
- 11/16/2004 Prescription Drug PA Criteria
- 06/16/2004 PA and HIPAA Updates
Acquisition Costs
Request
for Information: Acquisition Costs (04/08/2008)
- 04/08/2008 Department Request
- 04/08/2008 Drug Cost Spreadsheet
Other Resources
Other Resources (01/02/2013)
- Cost to Dispense Survey (06/2009)
- Drugs Requiring Prior Authorization (12/30/2011)
- EOB
R&R Crosswalk PDF and EOB R&R Crosswalk Excel (02/01/2011)
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. - Most Commonly Used NDCs (02/2011)
- NCPDP
D.0 Payer Sheet (07/2012)
Payer sheet for POS claims. - NCPDP
5.1 Payer Sheet (04/2011)
Payer sheet for POS claims. - Plan First Medicaid Non-Covered Agreement (07/2012)
- Rebateable Bulk Powders for Compound Medications (08/27/2008)
- Rebateable Manufacturers (01/02/2013)
- Self
Audit Policy and Procedure (04/2009)
CMS guidance and FAQs on tamper-resistant prescription pad laws - Tamper-Resistant Prescription Pads (09/2007)
- Tamper-Resistant Prescription Pad Vendors (11/2011)
- TPL Insurance Carrier ID List by Carrier ID and TPL Insurance Carrier ID List by Name (05/2012)
Key Contacts
Key Contacts (04/13/2012)
- Pharmacy (10/2011)
- Claims (03/2012)
- Client Eligibility (04/2012)
- HMK/CHIP (12/2010)
- Passport (03/2012)
- Policy Information (03/2012)
- Prior Authorization (03/2012)
- Public Assistance Offices (03/2012)
