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Montana Medicaid Prior (Rx) Authorization Form

Montana Medicaid prior authorization form is used by a physician to get permission to prescribe a non-preferred drug to a Medicaid patient. Once submitted, the form will be reviewed by the Department of Public Health and Human Services to ensure that the requested medication is the most appropriate and cost-effective option for the patient.
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Form can be faxed to: (406) 513-1928 (Local) or 1 (800) 294-1350 (Toll-Free)

Form can be mailed to: Drug Prior Authorization Unit, Mountain-Pacific Quality Health, 3404 Cooney Drive, Helena, MT 59602

Preferred Drug List