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(1) The insurer shall notify in writing the injured worker and the treating physician (who, for the purposes of this rule, also includes any other prescribing medical provider) that a claim constitutes a legacy claim in which the insurer will enforce the applicability of these formulary rules. 

(2) The notification required by (1) must include at least the following information:

(a) the name of the injured worker;

(b) the name of the treating physician or other prescribing medical provider;

(c) the name of each medication that is affected by the notice;

(d) the name and contact information of the claims examiner responsible for the injured worker's claim; and

(e) the date upon which the insurer will enforce the applicability of these formulary rules.

(3) This rule applies to a legacy claim on the latter of:

(a) April 1, 2020; or

(b) 90 days after the insurer provides notice as provided by (1).

(4) By not later than the applicability date of this rule pursuant to (3), the treating physician shall determine whether a transition plan is needed for an injured worker who is receiving:

(a) one or more drugs for which prior authorization is otherwise required; or

(b) drugs at a dosage level greater than recommended by the Montana Guidelines.

(5) The treating physician must state in writing whether the injured worker:

(a) should transition to "Y" status drugs or to medication dosages which are consistent with the recommendations of the Montana Guidelines; or

(b) should not undergo a transition from the existing medications because a transition is not medically appropriate.

(6) The treating physician must provide the basis for the medical provider's decision as required by ARM 24.29.1621. The explanation, and development of a transition plan as appropriate, constitutes a "by report" service (CPT code 99080).

(7) If the treating physician fails to provide the determination required in (5), by the date this rule becomes applicable to the claim pursuant to (3), these formulary rules will apply to prescriptions written for the injured worker.

(8) If the treating physician determines a transition from one or more drugs for which prior authorization required to a "Y" status drug is appropriate, or that a reduction in dosage is appropriate, the treating physician shall include in the worker's treatment plan a specific plan, including a projected time table or schedule, for transitioning the injured worker to care that is consistent with the Montana Guidelines.

(9) The treatment plan may, when determined by the treating physician to be medically necessary, include the provision of supportive services to the injured worker during the transition.

(10) Supportive services may be delivered in an out-patient or an in-patient setting, as appropriate, based upon the treating provider's transition plan. Supportive services that are reasonable and medically necessary constitute part of the primary medical services to which an injured worker with a legacy claim is entitled.

(11) Nothing in this rule prohibits the treating physician from proposing a treatment plan for transition prior to an insurer's authorization as provided in (1).


History: 39-71-203, 39-71-704, MCA; IMP, 39-71-704, MCA; NEW, 2018 MAR p. 2531, Eff. 1/1/19.

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