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.


Issue Date Pharmacy Clinical Edit and PDL Description
05/14/20 15 Day Limitation Fiscal Edit
05/14/20 15-Day Supply - Oral Oncology
01/09/20 ACE Inhibitors and ACE Inhibitors Diuretic Combinations PDL
01/09/20 ACE Inhibitors/Calcium Channel Blocker Combinations PDL
04/17/20 Acetaminophen Cumulative Dose Clinical Edit
08/17/20 Acne and Rosacea - Select Topical Agents Step Therapy Edit
07/09/20 Actinic Keratosis Agents – Topical PDL
08/17/20 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
08/17/20 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
04/02/20 Alzheimer’s Agents & Cholinesterase Inhibitors PDL 
07/07/11 Ampyra
10/03/19 Amylin Analogs PDL
07/09/20 Androgenic Agents – 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
04/02/20 Antiandrogenic Agents
07/09/20 Antibiotic Agents – Inhaled PDL
01/09/20 Anticoagulants Agents: Oral and Subcutaneous PDL
10/03/19 AntiDiabetic Combinations: Oral and Injectable PDL
04/02/20 Antiemetics-5-HT3, NK1 & Other Agents PDL
04/02/20 Antiemetics–THC Derivative Agents PDL
07/09/20 Antifungal Agents – Topical PDL
07/09/20 Antifungal (Onychomycosis – Candidiasis) Agents Oral PDL
07/09/20 Antihistamine Decongestant Combination - Low Sedating
07/09/20 Antihistamines – Intranasal PDL
07/23/20 Antihistamines - Ophthalmic
10/03/19 Antihyperuricemic Agents PDL
07/09/20 Anti-Migraine, Serotonin (5-HT1) Receptor Agents PDL
07/09/20 Antiparasitic Agents – Topical PDL
04/02/20 Anti-Parkinsonism MAOB Inhibitors PDL
04/02/20 Anti-Parkinsonism Non-Ergot Dopamine Agonists PDL
07/31/20 Antiplatelet Agents
04/02/20 Antipsychotics – 2nd Generation (Atypicals) Reference Drug List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
07/09/20 Antivirals – Herpes Oral PDL
9/17/20 Antiretrovirals, Treatment Reference Product List
07/23/20 Antivirals - Topical PDL
07/09/20 Atopic Dermatitis Agents (Immunomodulators)
10/10/19 Benzodiazepines (Select Oral) Clinical Edit
07/09/20 Benzoyl Peroxide-Antibiotic Combination PDL
07/09/20 Beta Adrenergic Agents Long Acting PDL
07/09/20 Beta Adrenergic Agents/Nebulized PDL
07/09/20 Beta Adrenergic Agents – 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
05/07/20 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)
09/03/20 Brand Over Generic
10/17/19 Butalbital Combo Clinical Edit
04/02/20 Calcitonin Gene-Related Peptide (CGRP) Inhibitors PDL
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
08/17/20 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
07/09/20 COPD Anticholinergic Agents PDL
05/07/20 Corlanor® Clinical Edit
07/09/20 Corticosteroids Oral – Inhaled PDL
07/09/20 Corticosteroids - Intranasal PDL
07/09/20 Corticosteroids - Ophthalmic PDL
07/09/20 Corticosteroids-Topical PDL
07/09/20 Cough and Cold PDL
10/03/19 Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL
04/11/19 Crysvita Clinical Edit
04/23/20 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Clinical Edit
07/23/20 Diabetic Supply Quantity Limit Fiscal Edit
01/30/20 Diacomit Clinical Edit
01/09/20 Direct Renin Inhibitors and Combinations PDL
07/17/20 Dose Optimization Fiscal Edit
10/03/19 DPP-IV Inhibitors PDL
01/09/20 Dry Eye Disease Agents PDL
08/17/20 Duchenne Muscular Dystrophy (DMD) Clinical Edit
10/03/19 Electrolyte Depleters PDL
03/05/20 Electrolyte Depleters – Potassium Lowering Agents PDL
02/13/20 Emsam®
05/07/20 Entresto Clinical Edit
08/17/20 Epidiolex® Clinical Edit
07/09/20 Epinephrine Self-Injectable Agents PDL
06/20/19 Equetro® Clinical Edit
10/03/19 Erythropoiesis Stimulating Agents PDL
07/30/20 Fabry Disease Clinical Edit
09/10/20 Fibromyalgia Agents PDL
10/03/19 Fluoroquinolones PDL
07/09/20 Fluoroquinolones – Ophthalmic PDL
07/09/20 Fluoroquinolones – Otic PDL
10/17/19 Gamifant Clinical Edit
10/03/19 Gastrointestinal(GI) Antibiotics – Oral PDL
04/02/20 GI Motility Agents PDL
07/30/20 Givlaari Clinical Edit
07/09/20 Glaucoma Agents PDL
10/03/19 GLP-1 Receptor Agonists PDL
04/02/20 Glucagon Agents PDL
10/03/19 Growth Hormones and Growth Factors PDL
10/03/19 Hep C (HCV) Therapy
04/02/20 Hereditary Angioedema Treatment Agents PDL
09/03/20 High Cost Medication Kits Fiscal Edit
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
07/09/20 Leukotriene Modifiers PDL
04/18/19 Luxturna Clinical Edit
10/03/19 Macrolides PDL
07/09/20 Mast Cell Stabilizers - Ophthalmic PDL
08/17/20 Megestrol Acetate
10/03/19 Methotrexate Products
05/21/20 Morphine Milligram Equivalent Accumulation
09/03/20 Multiple Sclerosis Agents PDL
02/20/20 Narcolepsy Inhibitors
04/02/20 Neuropathic Pain Agents PDL
01/09/20 Niacin Derivatives
08/17/20 Nocturnal Polyuria Clinical Edit
07/23/20 Non-Oral Contraceptives Fiscal Edit
04/02/20 NSAID Agents PDL
07/09/20 NSAIDs – Ophthalmic PDL
04/24/20 Opioid Dependence Agents PDL
04/02/20 Opioid Emergency Reversal Agents PDL
08/06/20 Opioid - Long Acting PDL
Opioid Prior Authorization Process for Prescribers
Opioid Prior Authorization Process for Pharmacy
Opioid Prior Authorization Form
05/28/20 Opioids, Combination Short-Acting Clinical Edit
Opioid Prior Authorization Form
05/28/20 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
07/09/20 Pancreatic Enzyme Agents PDL
02/06/20 Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit
10/03/19 Penicillins PDL
04/30/20 PrEP Fiscal Edit
01/09/20 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL
01/09/20 Proton Pump Inhibitors PDL
07/09/20 Psoriasis Agents - Oral PDL
07/09/20 Psoriasis Agents – Topical PDL
02/06/20 Psychotropic Medications Polypharmacy Clinical Edit
08/06/20 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
04/02/20 Respiratory Monoclonal Antibodies PDL
07/09/20 Retinoids – Topical PDL
10/03/19 Second Generation Sulfonylureas PDL
07/09/20 Sedative Hypnotics PDL
06/20/19 Selzentry® (Maraviroc)
08/17/20 Sickle Cell Disease Clinical Edit
08/07/20 Skeletal Muscle Relaxants PDL
01/23/20 SNRI Clinical Edit
10/03/19 Sodium - Glucose Co - Transporter 2 (SGLT2) PDL
06/04/20 Spinraza® Clinical Edit
08/17/20 Spravato® 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
08/17/20 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
04/02/20 Tramadol - like Agents PDL
04/23/20 Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit
09/10/20 Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit
01/09/20 Triglyceride Lowering Agents PDL
08/17/20 Typical Antipsychotics Clinical Edit
08/13/20 Ulcerative Colitis Oral Agents PDL
07/09/20 Ulcerative Colitis - Rectal PDL
04/17/20 Urinary Tract Antispasmodics PDL
10/03/19 Vaginal Antibiotics PDL
01/30/20 Zolgensma Clinical Edit
02/27/20 Zometa® (zoledronic acid)
07/01/20 Zulresso Clinical Edit