Pharmacy Clinical Edits and Preferred Drug Lists

MO HealthNet is continuing the state specific Preferred Drug List and Clinical Edit processes. The following is a listing of therapeutic classes that have been implemented. Please see the implementation schedule for proposed implementation dates for additional classes.

Quarterly Preferred Drug List Changes

Grandfathering Recommendations

Opioid Prior Authorization Process
Opioid Prior Authorization Process for Prescribers
Opioid Prior Authorization Process for Pharmacy
Opioid Prior Authorization Form

Preferred Drug Searchable Database

PDL List of Preferred and Non-Preferred Agents.

Issue Date Pharmacy Clinical Edit and PDL Description
02/06/20 15 Day Limitation Fiscal Edit
11/06/18 15-Day Supply - Oral Oncology
11/14/19 5-HTI Serotonin Receptor Agonists (Triptans) PDL
01/09/20 ACE Inhibitors and ACE Inhibitors Diuretic Combinations PDL
01/09/20 ACE Inhibitors/Calcium Channel Blocker Combinations PDL
07/11/19 Actinic Keratosis Agents – Topical PDL
01/09/20 ADHD Amphetamines – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
01/09/20 ADHD Amphetamines – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
01/09/20 ADHD Methylphenidate – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
01/09/20 ADHD Methylphenidate – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
01/09/20 ADHD Non-Stimulant Agents
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
04/04/19 Alzheimer’s Agents & Cholinesterase Inhibitors PDL 
07/07/11 Ampyra
10/03/19 Amylin Analogs PDL
07/11/19 Androgenic Agents – Topical PDL
01/09/20 Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations PDL
01/09/20 Angiotensin Receptor Blocker-Calcium Channel Blocker Combinations PDL
07/11/19 Antibiotic Agents – Inhaled PDL
01/09/20 Anticoagulants Agents: Oral and Subcutaneous PDL
10/03/19 AntiDiabetic Combinations: Oral and Injectable PDL
1/17/20 Antiemetics-5-HT3, NK1 & Other Agents PDL
04/04/19 Antiemetics–THC Derivative Agents PDL
11/07/19 Antifungal Agents – Topical PDL
07/11/19 Antifungal (Onychomycosis – Candidiasis) Agents PDL
07/11/19 Antihistamine Decongestant Combos
07/11/19 Antihistamines – Intranasal PDL
07/11/19 Antihistamines - Low Sedating
07/11/19 Antihistamines - Ophthalmic
10/03/19 Antihyperuricemic Agents PDL
10/03/19 Antiparasitic Agents – Topical PDL
04/04/19 Anti-Parkinsonism MAOB Inhibitors PDL
01/09/20 Antiplatelet Agents
06/13/19 Antipsychotics – 2nd Generation (Atypicals) Reference Drug List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
07/11/09 Antivirals - Topical PDL
08/08/19 Atopic Dermatitis Agents (Immunomodulators)
10/10/19 Benzodiazepines (Select Oral) Clinical Edit
07/11/19 Benzoyl Peroxide-Antibiotic Combination PDL
07/11/19 Beta Adrenergic Agents Long Acting PDL
07/11/19 Beta Adrenergic Agents/Nebulized PDL
03/20/20 Beta Adrenergic Beta Blockers - Short Acting PDL
01/09/20 Beta Adrenergic Blockers and Beta Adrenergic Blockers/Diuretic Combinations PDL
02/13/20 BiDil® Tablets Clinical Edit
10/03/19 Bile Salts Agents PDL
02/06/20 Biosimilar vs Reference Products Fiscal Edit
10/03/19 Bone Ossification Suppression Agents
02/13/20 Botulinum Toxin Clinical Edit
10/03/19 BPH Agents PDL (formerly Androgen Hormone Inhibitors)
03/20/20 Brand Over Generic
10/17/19 Butalbital Combo Clinical Edit
01/09/20 Calcium Channel Blockers (Dihydropyridines) PDL
01/09/20 Calcium Channel Blockers (Non-Dihydropyridines) PDL
06/21/18 Car T Cell Clinical Edit
10/03/19 Cephalosporin Antibiotics – Oral PDL
08/01/19 CGRP Inhibitors
10/24/19 Clobazam Agents Clinical Edit
10/03/19 Colony Stimulating Factors
04/02/20 Continuous Glucose Monitors (CGMs) Clinical Edit  Continuous Glucose Monitoring Device Prior Authorization
07/11/19 COPD Anticholinergic Agents PDL
12/03/18 Corlanor Clinical Edit
03/05/20 Corticosteroids Oral – Inhaled PDL
07/11/19 Corticosteroids - Intranasal PDL
07/11/19 Corticosteroids - Ophthalmic PDL
01/23/20 Corticosteroids-Topical PDL
07/12/19 Cough and Cold PDL
04/04/19 COX-2 Inhibitors PDL
10/03/19 Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL
04/11/19 Crysvita Clinical Edit
08/01/19 Diabetic Supply Quantity Limit Fiscal Edit
01/30/20 Diacomit Clinical Edit
01/09/20 Direct Renin Inhibitors and Combinations PDL
11/13/03 Dolgic LQ® (Acetaminophen/Butalbital/Caffeine)
03/17/20 Dose Optimization Fiscal Edit
10/03/19 DPP-IV Inhibitors PDL
01/09/20 Dry Eye Disease Agents PDL
02/06/20 Duchenne Muscular Dystrophy (DMD) Clinical Edit
10/03/19 Electrolyte Depleters PDL
03/05/20 Electrolyte Depleters – Potassium Lowering Agents PDL
02/13/2020 Emsam®
12/03/18 Entresto Clinical Edit
10/24/19 Epidiolex Clinical Edit
07/11/19 Epinephrine Self-Injectable Agents PDL
06/20/19 Equetro Clinical Edit®
10/03/19 Erythropoiesis Stimulating Agents PDL
08/01/17 Exondys 51® Clinical Edit
08/08/19 Fibromyalgia Agents PDL
10/03/19 Fluoroquinolones PDL
03/05/20 Fluoroquinolones – Ophthalmic PDL
11/14/19 Fluoroquinolones – Otic PDL
07/28/03 Forteo® (teriparatide injection / Parathyroid Hormone)
05/23/19 Galafold™ (migalastat) Clinical Edit
10/17/19 Gamifant Clinical Edit
10/03/19 Gastrointestinal(GI) Antibiotics – Oral PDL
04/04/19 GI Motility Agents PDL
01/09/20 Glaucoma Agents PDL
10/03/19 GLP-1 Receptor Agonists PDL
10/03/19 Growth Hormones and Growth Factors PDL
10/03/19 Hep C (HCV) Therapy
08/12/19 Hereditary Angioedema Treatment Agents PDL
07/11/19 Herpes Antivirals – Oral PDL
01/09/20 Homozygous Familial Hyperchloesterolemia (HFHC) Products PDL
08/01/19 Hospice Fiscal Edit
10/03/19 Insulins Long Acting PDL
10/03/19 Insulins Mix PDL
01/09/20 Insulins-Non-Analog PDL
10/03/19 Insulins Rapid Acting PDL
04/11/19 Jynarque Clinical Edit
01/30/20 Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit
07/11/19 Leukotriene Modifiers PDL
04/18/19 Luxturna Clinical Edit
10/03/19 Macrolides PDL
07/11/19 Mast Cell Stabilizers - Ophthalmic PDL
04/18/19 Megestrol Acetate
10/03/19 Methotrexate Products
04/04/19 Morphine Milligram Equivalent Accumulation
12/05/19 Multiple Sclerosis Agents PDL
02/20/20 Narcolepsy Inhibitors
04/04/19 Neuropathic Pain Agents PDL
01/09/20 Niacin Derivatives
08/22/19 Nocturnal Polyuria Clinical Edit
04/04/19 Non-Ergot Dopamine Receptor Agonists PDL
11/21/19 Non-Oral Contraceptives Fiscal Edit
03/12/20 NSAID Agents PDL
07/11/19 NSAIDs – Ophthalmic PDL
05/03/07 Nubain®
10/10/19 Opioid Dependence Agents PDL
04/04/19 Opioid Emergency Reversal Agents PDL
01/09/20 Opioid - Long Acting PDL
Opioid Prior Authorization Form
04/11/19 Opioids, Combination Short-Acting Clinical Edit
Opioid Prior Authorization Form
05/16/19 Opioids, Short Acting Clinical Edits
Opioid Prior Authorization Form
10/03/19 Oral AntiDiabetic: Alpha - Glucosidase Inhibitors PDL
10/03/19 Oral AntiDiabetic: Biguanides PDL
10/03/19 Oral AntiDiabetic: Meglintinides PDL
10/03/19 Oral AntiDiabetic: Thiazolidinediones PDL
07/24/19 Orilissa Clinical Edit
02/20/20 Oxandrin® Clinical Edit
10/17/19 Oxervate Clinical Edit
04/18/19 Palynziq Clinical Edit
07/11/19 Pancreatic Enzyme Agents PDL
02/06/20 Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit
10/03/19 Penicillins PDL
01/09/20 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL
01/09/20 Proton Pump Inhibitors PDL
07/11/19 Psoriasis Agents - Oral PDL
02/06/20 Psoriasis Agents – Topical PDL
02/06/20 Psychotropic Medications Polypharmacy Clinical Edit
01/09/20 Pulmonary Arterial Hypertension (PAH) Agents (Inhaled and Injectable) PDL
01/09/20 Pulmonary Arterial Hypertension (PAH) Agents – Oral Endothelin Receptor Antagonists (ETRAs)
01/09/20 Pulmonary Arterial Hypertension (PAH) Agents – Oral Phosphodiesterase-5 (PDE5)
01/09/20 Pulmonary Arterial Hypertension (PAH) Agents – Oral Prostacyclin Pathway Agonist
02/20/20 Ranexa® Clinical Edit
11/14/19 Respiratory Monoclonal Antibodies PDL
07/11/19 Retinoids – Topical PDL
10/12/16 Ribavirins PDL
10/03/19 Second Generation Sulfonylureas PDL
04/02/20
07/09/20		 Sedative Hypnotics PDL
Sedative Hypnotics PDL
06/20/19 Selzentry® (Maraviroc)
12/12/19 Skeletal Muscle Relaxants PDL
01/23/20 SNRI Clinical Edit
10/03/19 Sodium - Glucose Co - Transporter 2 (SGLT2) PDL
01/30/20 Spinraza® Clinical Edit
01/23/20 SSRI Clinical Edit
01/09/20 Statins (HMG Co-A Reductase Inhibitors) and Combination Products PDL
01/09/20 Sympatholytic Agents PDL
02/27/20 Synagis Clinical Edit
08/22/19 Systemic Antifungals Clinical Edit
10/03/19 Targeted Immune Modulators (Formerly Biologics - DMARDs) PDL
10/03/19 Tetracyclines PDL
10/03/19 ThromobocytopeniaTreatment Agents PDL
04/04/19 Tramadol - like Agents PDL
02/27/20 Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit
01/09/20 Triglyceride Lowering Agents PDL
12/08/19 Ulcerative Colitis Oral Agents PDL
07/11/19 Ulcerative Colitis - Rectal PDL
10/03/19 Urinary Tract Antispasmodics PDL
10/03/19 Vaginal Antibiotics PDL
03/07/03 Voriconazole (Vfend) / Antifungal
01/30/20 Zolgensma Clinical Edit
02/27/20 Zometa® (zoledronic acid)