Montana Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Montana Medicaid prior authorization form is used by a physician to get permission to prescribe a drug that requires prior-authorization from Medicaid. The DPPHS provides Medicaid members with basic healthcare services, but sometimes a patient is prescribed medication that is not covered by Medicaid. The primary care case management (PCCM) program for Montana Medicaid is Passport to Health. However, Mountain-Pacific Quality Health provides Medicaid utilization review and management services for the Department of Public Health and Human Services (DPHHS) as well. Once submitted, the prior authorization form will be reviewed to ensure that the requested medication is the most appropriate and cost-effective option for the patient.

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

How to Write

Step 1 – Select either physician or pharmacy at the top of the form.

Step 2 – Enter the patients’ full name, their Medicaid ID number, and date of birth. Below that enter the dates covered by this request.

Step 3 – Provide the physician’s NPI, phone number, fax number, name, and address.

Step 4 – Type in the pharmacy’s NPI, phone number, fax number, name, and address.

Step 5 – In the Drug to be Authorized section, enter the name of the drug, the strength, and directions of administration.

Step 6 – A diagnosis is also required, explaining the prescriber’s medical reasoning for suggesting this particular medication over similar options.