Sorry, you need to enable JavaScript to visit this website.
Skip to main content

Montana State Based Drug List Change Notification (Commercial)

Updates on Existing Criteria

October 2025. The following changes to criteria are effective October 1, 2025:


Removed from Formulary

  • Androderm patch

     

Prior Authorization

  • Remove Prior Authorization
    • Depo-Estradiol oil
    • Estradiol twice weekly patch
    • Estradiol weekly patch
    • Dotti patch
    • Estradiol tablet
    • Estradiol gel
    • Menest tablet
    • Elestrin gel
    • Estrogel gel
    • Evamist solution
    • Premarin tablets
    • Testosterone cypionate solution
    • Testosterone enanthate solution
    • Testosterone gel
    • Testosterone patch
    • Climara patch
    • Estrace tablets
    • Estradiol valerate oil
    • Lyllana patch
    • Menostar patch
    • Methyltestosterone capsule
    • Minivelle patch
    • Premarin solution
    • Vivelle-dot patch
    • Alvesco inhalation
    • Breztri inhalation
    • Bronchitol capsule
    • Zileuton extended release tablet
    • Apidra solution
    • Basaglar KwikPen solution
    • Humulin 70/30 and 70/30 KwikPen solution
    • Insulin Degludec and Degludec FlexTouch solution
    • Insulin Glargine and GlargineSolostar solution
    • Insulin Glargine-yfgn solution
    • Novolin 70/30 ReliOn and Flexpen Relion solution
    • Semglee solution
    • Xultophy solution
    • Alosetron tablet
    • Alosetron tablet
    • Dapagliflozin pro-metformin extended-release tablet
    • Dapagliflozin propanediol tablet
    • Deflazacort tablet and suspension
    • Diclofenac potassium (migraine) packet
    • Dihydroergotamine mesylate solution
    • Flucytosine capsule
    • Isosorb dinitrate-hydralazine tablet
    • Ivabradine tablet
    • Metoclopramide tablet
    • Naproxen-esomeprazole magnesium delayed release tablet
    • Nilutamide tablet
    • Ofloxacin tablet
    • Orphenadrine-acetaminophen-caffeine tablet
    • Paromomycin sulfate capsule
    • Penicillamine capsule
    • Phenoxybenzamine capsule
    • Posaconazole suspension
    • Posaconazole suspension and delayed release tablet
    • Pyrimethamine tablet
    • Rufinamide suspension
    • Rufinamide tablet
    • Rufinamide tablet
    • Sodium phenylbutyrate powder
    • Sumatriptan-naproxen sodium tablet
    • Tadalafil tablet
    • Trientine capsule
    • Voriconazole suspension 

 

Remove Step Therapy

  • Acyclovir cream
  • Brimonidine gel
  • Dutasteride-Tamsulosin capsule
  • Fenoprofen capsule
  • Fesoterodine tablet
  • Fluoxetine capsule delayed release 90 mg
  • Frovatriptan tabket
  • Gabapentin tablet
  • Glutamine (Sickle Cell) powder
  • Megestrol acetate suspension 625 mg/5mL
  • Mirabegron tablet
  • Penciclovir cream
  • Zolmitriptan nasal spray

 

See the PacificSource Drug Lists page for the current drug list.