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.

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.

Effective Date Pharmacy Clinical Edit and PDL Description Upcoming Policy Changes
01/12/23 ACE Inhibitors and ACE Inhibitors/Diuretic Combinations PDL
01/12/23 ACE Inhibitor/Calcium Channel Blocker Combinations PDL
05/25/23 Acetaminophen Cumulative Dose Clinical Edit
07/27/23 Acne and Rosacea - Select Topical Agents Step Therapy Edit
07/13/23 Actinic Keratosis Agents – Topical PDL
08/24/23 Anti-Amyloid Monoclonal Antibody Clinical Edit (formerly the Aduhelm Clinical Edit)
09/14/23 ADHD, Amphetamines Long Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
05/18/23 ADHD, Amphetamines Short Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
05/18/23 ADHD, Methylphenidate Long Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
05/18/23 ADHD, Methylphenidate Short Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
05/18/23 ADHD, Non-Stimulants PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
10/05/23 Alpha-Glucosidase Inhibitors
01/12/23 Alpelisib Clinical Edit
06/02/23 Alzheimer’s Agents & Cholinesterase Inhibitors PDL
10/26/23 Ampyra
10/05/23 Amylin Analogs PDL
07/06/23 Androgenic Agents PDL
01/12/23 Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations PDL
01/12/23 Angiotensin Receptor Blocker-Calcium Channel Blocker Combinations PDL
04/06/23 Antiandrogenic Agents PDL
07/06/22 Antibiotic Agents – Inhaled PDL
01/12/23 Antibiotics, Gastrointestinal (GI) Oral PDL
01/12/23 Antibiotics, Mupirocin Topical PDL
01/12/23 Antibiotics, Vaginal PDL
07/13/23 Anticholinergics, Long Acting Beta Adrenergic(LABA) Combinations PDL Edit
07/06/23 Anticholinergics, Long Acting Beta Adrenergic (LABA)-Inhaled Corticosteroid (ICS) Combinations and Phosphodiesterase 4 (PDE4) Inhibitors PDL Edit
08/31/23 Anticholinergics, Long Acting Inhaled PDL Edit
07/06/23 Anticholinergics, Short Acting and Combinations Inhaled PDL Edit
03/02/2023 Anticoagulants: Oral and Subcutaneous PDL
04/06/23 Anticonvulsants, Dravet Syndrome PDL Edit
01/12/23 Anticonvulsants, Rescue Agents PDL
04/06/23 Antiemetic 5-HT3, NK1 & Other Select Agents, Non-Injectable PDL
04/06/23 Antiemetic 5-HT3, NK1 Agents, Injectable PDL
07/06/23 Antifungals (Onychomycosis/Candidiasis), Oral PDL
09/07/23 Antifungal Agents – Topical PDL
07/06/23 Antihistamines and Antihistamine/Decongestant Combinations, Second Generation PDL
07/06/23 Antihistamines, Intranasal PDL
07/06/23 Antihistamines, Ophthalmic PDL
01/12/23 Antihyperuricemic Agents PDL
04/06/23 Anti-Migraine, Alternative Oral Agents PDL
04/06/23 Anti-Migraine, Serotonin (5-HT1) Receptor Agents PDL
10/06/22 Antiparasitics, Topical PDL Edit
04/06/23 Anti-Parkinsonism MAO-B Inhibitors PDL
04/06/23 Anti-Parkinsonism Non-Ergot Dopamine Agonists PDL
01/12/23 Antiplatelet Agents PDL
04/06/2023 Antipsychotics - 1st Gen (Typical) Clinical Edit
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
04/06/23 Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
Antipsychotics - 2nd Generation (Atypical) Depot Agents Resource List
07/20/23 Antipsychotics - 2nd Generation (Atypical) Oral & Transdermal Agents Resource List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
07/06/23 Antivirals – Herpes Oral PDL
06/15/23 Antiretroviral Therapy (ART) PDL
07/06/23 Antivirals - Topical PDL
10/05/23 Atopic Dermatitis Agents, Immunomodulators PDL Edit
01/12/23 Benign Prostatic Hyperplasia Agents PDL Edit
04/20/23 Benzodiazepines (Select Oral) Clinical Edit
Benzodiazepine Prior Authorization Form
10/12/23 Benzoyl Peroxide-Antibiotic Combination PDL
11/02/23 Besremi Clinical Edit
07/06/23 Beta Adrenergic Agents Long Acting PDL
07/06/23 Beta Adrenergic Agents/Nebulized PDL
07/06/23 Beta Andrenergic Agents - Short Acting
01/12/23 Beta Adrenergic Blockers and Beta Adrenergic Blockers-Diuretic Combinations PDL
10/05/23 Biguanides & Combination Agents PDL
01/12/23 Bile Salts Agents PDL
10/05/23 Biosimilar vs Reference Products Fiscal Edit
10/05/23 Bleeding Disorder Agents PDL
01/12/23 Bone Ossification Agents PDL
10/20/22 Botulinum Toxin Clinical Edit
11/09/23 Brand Over Generic Fiscal Edit
04/20/23 Butalbital Combinations without Codeine Clinical Edit
04/06/23 Calcitonin Gene-Related Peptide (CGRP) Inhibitors PDL
01/12/23 Calcium Channel Blockers (Dihydropyridines) PDL
01/12/23 Calcium Channel Blockers (Non-Dihydropyridines) PDL
04/27/23 Camyzos Clinical Edit
01/19/23 Carbamoyl Phosphate Synthetase 1 Activators PDL
11/02/23 Car T Cell Clinical Edit
01/12/23 Cephalosporin Agents PDL
10/05/23 Colony Stimulating Factors PDL
06/15/23 Continuous Glucose Monitors (CGMs) Clinical Edit
Continuous Glucose Monitoring Device & Tubeless Insulin Pump Prior Authorization
04/27/23 Corlanor® Clinical Edit
11/02/23 Corticosteroids Oral – Inhaled PDL
Asthma SMART Therapy
07/06/23 Corticosteroids - Ophthalmic PDL
07/13/23 Corticosteroids-Topical PDL
07/06/23 Corticosteroids & Rhinitis Agents - Intranasal PDL
07/06/23 Cough and Cold PDL
10/05/23 Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL
10/26/23 Crysvita Clinical Edit
04/06/23 Cyclin-Dependent Kinase (CDK) 4-6 Inhibitors PDL Edit
05/04/23 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Clinical Edit
Cystic Fibrosis Treatment Request
11/02/23 C5 Complement Inhibitors Clinical Edit
11/02/23 Daybue Clinical Edit
04/06/23 Diabetic Supply Quantity Limit Fiscal Edit
01/12/23 Direct Renin Inhibitors and Combinations PDL
12/01/22 DisposeRx Excessive Therapy Edit
11/16/23 Dose Optimization Fiscal Edit
10/05/23 DPP-IV Inhibitors PDL
10/26/23 Duchenne Muscular Dystrophy (DMD) Clinical Edit
01/12/23 Electrolyte Depleting Agents, Phosphate Lowering PDL
02/16/23 Electrolyte Depleting Agents, Potassium Lowering PDL
05/04/23 Empaveli Clinical Edit
10/20/22 Emsam® Clinical Edit
11/02/23 Enjaymo Clinical Edit
01/12/23 Entresto Clinical Edit
05/04/23 Enzyme Deficiency, Select Agents Clinical Edit
07/06/23 Epinephrine Self-Injectable Agents PDL
10/05/23 Erythropoiesis Stimulating Agents PDL
05/25/23 Extended Supply Fiscal Edit
08/03/23 Fabry Disease Clinical Edit
04/06/23 Fibromyalgia Agents PDL
11/02/23 Filspari Clinical Edit
01/12/23 Fluoroquinolones, Oral PDL
07/06/23 Fluoroquinolones – Ophthalmic PDL
10/06/23 Fluoroquinolones – Otic PDL
11/02/23 Gamifant Clinical Edit
09/21/23 GI Motility Agents PDL
11/02/23 Givlaari Clinical Edit
07/06/23 Glaucoma Agents PDL
10/05/23 GLP-1 Receptor Agonists & Combination Agents PDL
04/06/23 Glucagon Agents PDL
10/05/23 Growth Hormones & Growth Hormone Releasing Factors, Select Agents PDL
10/05/23 Growth Hormones Somatropin Agents PDL
Growth Hormones, Somatropin Agents Prior Authorization Form
05/11/23 HBV Nucleotide Analog Fiscal Edit
08/03/23 Hemgenix Clinical Edit
07/13/23 Hepatitis C Agents PDL Edit
Hepatitis C Treatment Prior Authorization
04/06/23 Hereditary Angioedema Treatment Agents PDL
04/20/23 High Risk Therapies Clinical Edit
04/27/23 Homozygous Familial Hypercholesterolemia (HoFH) Agents PDL
07/20/23 Hospice Fiscal Edit
08/03/23 Imcivree Clinical Edit
10/20/22 Immunoglobulins (IVIG and SCIG) Clinical Edit
07/06/23 Inflammatory Bowel Disease Agents, Oral PDL Edit (formerly Ulcerative Colitis Agents, Oral PDL Edit)
07/06/23 Inflammatory Bowel Disease Agents, Rectal PDL Edit (formerly Ulcerative Colitis Agents, Rectal PDL Edit)
03/30/2023 Insulin Pumps - Tubeless Clinical Edit
10/05/23 Insulins Long Acting PDL
10/05/23 Insulins Mix PDL
10/05/23 Insulins-Non-Analog PDL
10/05/23 Insulins Rapid Acting PDL
10/26/23 Iron – Injectable Step Therapy Edit
08/03/23 Isturisa Clinical Edit
11/02/23 Joenga Clinical Edit
01/12/23 Keratoconjunctivitis Agents PDL (formerly Dry Eye Disease Agents)
04/27/23 Kerendia Clinical Edit
11/02/23 Koselugo Clinical Edit
10/20/22 Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit
7/13/23 Leukotriene Modifiers PDL
10/05/23 Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Non-Oral PDL
10/05/23 Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Oral PDL
11/02/23 Luxturna Clinical Edit
01/12/23 Macrolides PDL
11/30/23 Manufacturers Requiring Prior Authorization Fiscal Edit
07/06/23 Mast Cell Stabilizers - Ophthalmic PDL
10/05/23 Meglitinide Agents PDL
07/21/22 Megestrol Acetate Clinical Edit
10/05/23 Methotrexate Agents PDL
04/06/23 Mitogen-activated Extracellular Kinase Inhibitors (MEKi) & B-raf Kinase Inhibitors (BRAFi) PDL Edit
04/20/23 Morphine Milligram Equivalent Accumulation Clinical Edit
10/05/23 Multiple Sclerosis, Injectable Agents PDL
10/05/23 Multiple Sclerosis, Oral Agents PDL
10/20/22 Narcolepsy Inhibitors Clinical Edit
11/02/23 Neuromyelitis Optica Spectrum Disorder (NMOSD) Clinical Edit
04/06/23 Neuropathic Pain Agents PDL
01/12/23 Niacin Derivatives PDL
05/11/23 Non-Oral Contraceptives Fiscal Edit
04/06/23 NSAID Agents PDL
07/06/23 NSAIDs – Ophthalmic PDL
10/20/22 Nuedexta Clinical Edit
08/03/23 Nulibry Clinical Edit
04/06/23 Opioid Emergency Reversal Agents PDL
04/06/23 Opioid - Long Acting PDL
Opioid Prior Authorization Form
04/06/23 Opioid and Select Alcohol Dependence Agents PDL Edit
04/20/23 Opioids, Short Acting Clinical Edits
Opioid Prior Authorization Form
05/04/23 Out-of-State, Non-Bordering Pharmacies Fiscal Edit
10/20/22 Oxandrin® Clinical Edit
05/11/23 Oxazolidinone Fiscal Edit
08/03/23 Oxervate Clinical Edit
08/03/23 Oxlumo Clinical Edit
10/20/22 Palforzia Clinical Edit
10/20/22 Palynziq Clinical Edit
07/06/23 Pancreatic Enzyme Agents PDL Edit
01/05/23 Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit
01/12/23 Penicillin Agents PDL
05/04/23 Pompe Disease Clinical Edit
10/05/2023 Prior Authorization Required Fiscal Edit
01/12/23 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL
01/12/23 Proton Pump Inhibitors PDL
10/05/23 Psoriasis Agents - Oral PDL
10/26/23 Psoriasis Agents – Topical PDL
02/23/23 Psychotropic Medications Polypharmacy Clinical Edit
Psychotropic Medications Polypharmacy Prior Authorization Form
01/12/23 Pulmonary Arterial Hypertension (PAH) Agents, Endothelin Receptor Antagonists (ETRAs) PDL
03/02/2023 Pulmonary Arterial Hypertension (PAH) Agents, Phosphodiesterase-5 (PDE5) and Soluble Guanylate Cyclase (SGC) Stimulators PDL)
01/12/23 Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Inhaled PDL
01/12/23 Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Injectable PDL
01/12/23 Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Oral PDL
10/20/22 Ranolazine Clinical Edit (formerly Ranexa® Clinical Edit)
11/02/23 Reblozyl Clinical Edit
12/08/22 Retinoids – Topical PDL
10/19/23 RSV Prophylaxis – Pediatric Clinical Edit
Synagis Prior Authorization Form
08/03/23 Scenesse Clinical Edit
04/06/23 Sedative Hypnotics PDL
05/11/23 Selzentry Clinical Edit
07/20/23 Sickle Cell Disease Clinical Edit
05/18/23 Skeletal Muscle Relaxants PDL
05/04/23 Skysona Clinical Edit
10/20/22 SNRI Clinical Edit
10/05/23 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors & Combination Agents PDL
04/06/23 Somatostatin Analogs PDL Edit
01/12/23 Spinal Muscular Atrophy (SMA) Clinical Edit
07/21/22 Spravato® Clinical Edit
10/20/22 SSRI Clinical Edit
01/12/23 Statins (HMG Co-A Reductase Inhibitors) and Combination Products PDL
10/05/23 Sulfonylurea Agents, Second Generation PDL
01/12/23 Sympatholytics PDL Edit
07/20/23 Systemic Antifungals Clinical Edit
10/05/23 Targeted Immune Modulators, IL-17A Antibody/IL-17 Receptor Antagonists PDL
10/05/23 Targeted Immune Modulators, IL-23 Inhibitors & IL-23/IL-12 Inhibitors PDL
10/05/23 Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL
10/05/2023 Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL
10/05/2023 Targeted Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies PDL (formerly Respiratory Monoclonal Antibody PDL)
Target Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies Prior Authorization
10/05/23 Targeted Immune Modulators, Select Agents PDL
10/05/23 Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL
10/26/22 Targeted Immune Modulators, Small Molecule JAK Clinical Edit
08/03/23 Tavneos Clinical Edit
11/02/23 Tepezza Clinical Edit
01/12/23 Tetracyclines PDL
10/05/23 Thiazolidinediones & Combination Agents PDL
10/05/23 Thromobocytopenia Agents PDL
10/19/23 Tolvaptan Clinical Edit
08/31/23 Tramadol - Like Agents PDL
04/20/23 Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit
01/12/23 Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit
01/12/23 Triglyceride Lowering Agents PDL
08/03/23 Tzield Clinical Edit
10/05/23 Urinary Tract Antispasmodics PDL
04/27/23 Verquvo Clinical Edit
04/06/23 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors PDL Edit
08/03/23 Voxzogo Clinical Edit
11/02/23 Vyvgart Clinical Edit 
10/20/22 Xcopri Clinical Edit
08/03/23 Zokinvy Clinical Edit
10/19/23 Zometa Clinical Edit
05/04/23 Ztalmy Clinical Edit
07/20/23 Zulresso Clinical Edit
05/04/23 Zynteglo Clinical Edit
05/18/23 15 Day Supply – Oral Oncology Fiscal Edit