Administrative Rules of Montana
Department 24 - LABOR AND INDUSTRY
Chapter 24.29 - WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE
Subchapter 24.29.16 - Utilization and Treatment Guidelines
Rule 24.29.1624 - INTEGRATION OF FORMULARY WITH MONTANA UTILIZATION AND TREATMENT GUIDELINES - WHEN PRIOR AUTHORIZATION IS REQUIRED

(1) The formulary is considered to be a part of the Montana Guidelines established by the department.

(2) A medical provider is expected to write a prescription for medication in accordance with the Montana Guidelines, as adopted by ARM 24.29.1611, and in accordance with the formulary adopted by ARM 24.29.1616.

(3) Because the formulary is part of the Montana Guidelines, medical providers are required to prescribe in accordance with the provisions of the formulary unless the provider can sufficiently articulate sound medical reasoning to vary from the formulary.

(4) Insurers shall pay for medications that are prescribed in a manner consistent with the formulary, subject to the medical provider furnishing documentation as required by ARM 24.29.1621. Payments for medications are subject to the provisions of 39-71-727, MCA.

(5) Pursuant to the formulary, prior authorization for an injury appropriate medication is not required as follows:

(6) Pursuant to the formulary, prior authorization for a medication is required as follows:

(7) The prior authorization process described in ARM 24.29.1621 applies to formulary matters, except that:

(8) An insurer may delegate prior authorization decisions pertaining to the formulary to a PBM or other agent with which it contracts. An insurer has the legal responsibility for the decisions made by the PBM on behalf of the insurer.

(9) The delegation by an insurer of prior authorization decisions pertaining to the formulary to a PBM or other agent does not, in and of itself, violate the requirement of 39-71-107, MCA, that all claims be examined by a claims examiner in Montana.