Pharmacy Clinical Edits and Preferred Drug Lists

MO HealthNet is continuing the state specific Preferred Drug List and Clinical Edit processes. MO HealthNet utilizes a real-time prior authorization rules engine in order to approve medications for MO HealthNet participants when they meet certain criteria in their paid claim history. In order to process claims quickly and to ensure diagnosis codes are still relevant, the transparent prior authorization system will look back in the participant’s MO HealthNet paid claim history for a specified amount of time from the date of claim submission. In general, the lookbacks outlined below will apply to the transparent lookback period. Should the lookback period be defined for a different period of time other than the standards below, it will be noted in the individual edit. If the patient has more history relevant to the current request, the provider will need to contact the Pharmacy Helpdesk at 800-392-8030 or by fax at 573-636-6470.

Lookbacks:
Diagnosis Codes (excluding cancer): 2 years
Diagnosis Codes (cancer): 6 months
Medication Trial: 2 years
Inferred Diagnosis based on medications: 90 days

The following is a listing of therapeutic classes that have been implemented. Please see the implementation schedule for proposed implementation dates for additional classes.