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.


Opioid Policy Update

Preferred Drug Searchable Database

PDL List of Preferred and Non-Preferred Agents.

Issue Date Pharmacy Clinical Edit and PDL Description
05/19/22 15 Day Limitation Fiscal Edit
05/19/22 15 Day Supply - Oral Oncology
01/06/22 ACE Inhibitors and ACE Inhibitors Diuretic Combinations PDL
01/06/22 ACE Inhibitors/ACE Inhibitors-Calcium Channel Blocker Combinations PDL
05/05/22 Acetaminophen Cumulative Dose Clinical Edit
08/05/21 Acne and Rosacea - Select Topical Agents Step Therapy Edit
07/01/21 Actinic Keratosis Agents – Topical PDL
01/27/22 Aduhelm Clinical Edit
02/03/22 ADHD Amphetamines – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
02/03/22 ADHD Amphetamines – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
03/03/22 ADHD Methylphenidate – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
02/03/22 ADHD Methylphenidate – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
02/03/22 ADHD Non-Stimulant Agents
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form
10/14/21 Alpha-Glucosidase Inhibitors
04/07/22 Alzheimer’s Agents & Cholinesterase Inhibitors PDL 
11/11/21 Ampyra
10/14/21 Amylin Analogs PDL
07/01/21 Androgenic Agents – PDL
01/06/22 Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations PDL
01/06/22 Angiotensin Receptor Blocker-Calcium Channel Blocker Combinations PDL
04/07/22 Antiandrogenic Agents
07/01/21 Antibiotic Agents – Inhaled PDL
10/14/21 Antibiotics, Mupirocin Topical PDL
01/06/22 Anticoagulants Agents: Oral and Subcutaneous PDL
06/01/22 Anticonvulsants, Dravet Syndrome PDL Edit
01/06/22 Anticonvulsants, Rescue Agents PDL
04/07/22 Antiemetic 5-HT3, NK1 & Other Select Agents, Non-Injectable PDL
04/07/22 Antiemetic 5-HT3, NK1 Agents, Injectable PDL
04/07/22 Antiemetics–THC Derivative Agents PDL
07/01/21 Antifungal Agents - Oral PDL
07/01/21 Antifungal Agents – Topical PDL
07/01/21 Antihistamine Decongestant Combination - 2nd Generation
07/01/21 Antihistamines – Intranasal PDL
02/03/22 Antihistamines - Ophthalmic
10/14/21 Antihyperuricemic Agents PDL
04/07/22 Anti-Migraine, Alternative Oral Agents PDL
04/07/22 Anti-Migraine, Serotonin (5-HT1) Receptor Agents PDL
07/29/21 Antiparasitic Agents – Topical PDL
04/07/22 Anti-Parkinsonism MAOB Inhibitors PDL
04/28/22 Anti-Parkinsonism Non-Ergot Dopamine Agonists PDL
01/06/22 Antiplatelet Agents
04/07/22 Antipsychotics - 1st Gen (Typical) Clinical Edit
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
04/07/22 Antipsychotics – 2nd Generation (Atypicals) Reference Drug List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old
07/01/21 Antivirals – Herpes Oral PDL
05/12/22 Antiretroviral Therapy (ART) PDL
07/01/21 Antivirals - Topical PDL
07/01/21 Atopic Dermatitis Agents (Immunomodulators)
10/14/21 Benign Prostatic Hyperplasia Agents PDL Edit
04/28/22 Benzodiazepines (Select Oral) Clinical Edit
07/01/21 Benzoyl Peroxide-Antibiotic Combination PDL
07/08/21 Beta Adrenergic Agents Long Acting PDL
07/01/21 Beta Adrenergic Agents/Nebulized PDL
07/01/21 Beta Adrenergic Agents – Short Acting PDL
01/06/22 Beta Adrenergic Blockers and Beta Adrenergic Blockers-Diuretic Combinations PDL
04/28/22 BiDil® Tablets Clinical Edit
04/07/22 Bile Salts Agents PDL
05/19/22 Biosimilar vs Reference Products Fiscal Edit
10/14/21 Bone Ossification Suppression Agents
02/10/22 Botulinum Toxin Clinical Edit
06/09/22 Brand Over Generic
04/21/22 Butalbital Combo Clinical Edit
04/21/22 Butalbital Combo Excessive Therapy
04/07/22 Calcitonin Gene-Related Peptide (CGRP) Inhibitors PDL
05/26/22 Calcium Channel Blockers (Dihydropyridines) PDL
01/06/22 Calcium Channel Blockers (Non-Dihydropyridines) PDL
06/16/22 Car T Cell Clinical Edit
10/14/21 Cephalosporin Antibiotics – Oral PDL
08/05/21 Clobazam Agents Clinical Edit
10/14/21 Colony Stimulating Factors
02/10/22 Continuous Glucose Monitors (CGMs) Clinical Edit
07/01/21 COPD Anticholinergic Agents PDL
04/28/22 Corlanor® Clinical Edit
07/01/21 Corticosteroids Oral – Inhaled PDL
Asthma SMART Therapy
07/01/21 Corticosteroids - Intranasal PDL
10/14/21 Corticosteroids - Ophthalmic PDL
11/04/21 Corticosteroids-Topical PDL
07/01/21 Cough and Cold PDL
10/14/21 Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL
10/28/21 Crysvita Clinical Edit
04/07/22 Cyclin-Dependent Kinase (CDK) 4-6 Inhibitors PDL Edit
07/15/21 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Clinical Edit
05/12/22 Diabetic Supply Quantity Limit Fiscal Edit
01/06/22 Direct Renin Inhibitors and Combinations PDL
05/26/22 Dose Optimization Fiscal Edit
10/14/21 DPP-IV Inhibitors PDL
02/24/22 Dry Eye Disease Agents PDL
11/18/21 Duchenne Muscular Dystrophy (DMD) Clinical Edit
10/14/21 Electrolyte Depleters – Phosphate Lowering Agents PDL
10/14/21 Electrolyte Depleters – Potassium Lowering Agents PDL
04/21/22 Empaveli Clinical Edit
02/10/22 Emsam® Clinical Edit
10/21/21 Entresto Clinical Edit
07/01/21 Epinephrine Self-Injectable Agents PDL
02/17/22 Equetro® Clinical Edit
10/14/21 Erythropoiesis Stimulating Agents PDL
05/12/22 Extended Supply Fiscal Edit
07/29/21 Fabry Disease Clinical Edit
05/26/22 Fibromyalgia Agents PDL
10/14/21 Fluoroquinolones PDL
07/01/21 Fluoroquinolones – Ophthalmic PDL
07/01/21 Fluoroquinolones – Otic PDL
11/18/21 Gamifant Clinical Edit
10/14/21 Gastrointestinal (GI) Antibiotics – Oral PDL
04/07/22 GI Motility Agents PDL
07/29/21 Givlaari Clinical Edit
07/01/21 Glaucoma Agents PDL
11/18/21 GLP-1 Receptor Agonist PDL
04/07/22 Glucagon Agents PDL
11/11/21 Gonadotropin Releasing Hormone (GnRH) Antagonists – Oral Clinical Edit (formerly known as Elagolix Clinical Edit)
10/14/21 Growth Hormones & Growth Hormone Releasing Factors, Select Agents PDL
10/14/21 Growth Hormones Somatropin Agents PDL
Growth Hormones, Somatropin Agents Prior Authorization Form
11/04/21 HBV Nucleotide Analog Fiscal Edit
07/01/21 Hep C (HCV) Therapy
Hepatitis C Treatment Prior Authorization
04/07/22 Hereditary Angioedema Treatment Agents PDL
04/07/22 High Risk Therapies Clinical Edit
04/07/22 Homozygous Familial Hypercholesterolemia (HFHC) Products PDL
03/03/22 Hospice Fiscal Edit
11/18/21 Imcivree Clinical Edit
02/10/22 Immunoglobulins Clinical Edit
02/03/22 Insulin Pumps - Tubeless Clinical Edit
06/01/22 Insulins Long Acting PDL
10/14/21 Insulins Mix PDL
10/14/21 Insulins-Non-Analog PDL
10/14/21 Insulins Rapid Acting PDL
11/11/21 Iron – Injectable Step Therapy Edit
04/22/21 Isturisa Clinical Edit
04/28/22 Kerendia Clinical Edit
11/18/21 Koselugo Clinical Edit
02/17/22 Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit
10/14/21 Leukotriene Modifiers PDL
10/14/21 Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Non-Oral PDL
11/18/21 Luxturna Clinical Edit
10/14/21 Macrolides PDL
05/26/22 Manufacturers Requiring Prior Authorization Fiscal Edit
07/01/21 Mast Cell Stabilizers - Ophthalmic PDL
07/29/21 Megestrol Acetate Clinical Edit
10/14/21 Methotrexate Products
04/07/22 Morphine Milligram Equivalent Accumulation
10/14/21 Multiple Sclerosis, Injectable Agents PDL
04/21/22 Multiple Sclerosis, Oral Agents PDL
02/03/22 Narcolepsy Inhibitors
02/10/22 Neuromyelitis Optica Spectrum Disorder (NMOSD) Clinical Edit
04/07/22 Neuropathic Pain Agents PDL
01/06/22 Niacin Derivatives
05/05/22 Non-Oral Contraceptives Fiscal Edit
04/07/22 NSAID Agents PDL
07/01/21 NSAIDs – Ophthalmic PDL
02/17/22 Nuedexta Clinical Edit
11/18/21 Nulibry Clinical Edit
04/07/22 Opioid Dependence Agents PDL
Alcohol Use Disorder Fact Sheet
04/07/22 Opioid Emergency Reversal Agents PDL
04/07/22 Opioid - Long Acting PDL
Opioid Prior Authorization Process for Prescribers
Opioid Prior Authorization Process for Pharmacy
Opioid Prior Authorization Form
07/15/21 Opioids, Combination Short-Acting Clinical Edit
04/07/22 Opioids, Short Acting Clinical Edits
Opioid Prior Authorization Form
10/14/21 Oral AntiDiabetic: Biguanides PDL
10/14/21 Oral AntiDiabetic: Meglintinides PDL
05/05/22 Out-of-State, Non-Bordering Pharmacies Fiscal Edit
01/27/22 Oxandrin® Clinical Edit
10/28/21 Oxazolidinone Fiscal Edit
11/18/21 Oxervate Clinical Edit
07/29/21 Oxlumo Clinical Edit
02/10/22 Palforzia Clinical Edit
11/18/21 Palynziq Clinical Edit
07/01/21 Pancreatic Enzyme Agents PDL
11/04/21 Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit
10/14/21 Penicillins PDL
04/21/22 Pompe Disease Clinical Edit
06/17/21 PrEP Fiscal Edit
05/19/22 Prior Authorization Required Fiscal Edit
01/06/22 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL
01/20/22 Proton Pump Inhibitors PDL
07/01/21 Psoriasis Agents - Oral PDL
07/01/21 Psoriasis Agents – Topical PDL
07/22/21 Psychotropic Medications Polypharmacy Clinical Edit
Psychotropic Medications Polypharmacy Prior Authorization Form
01/06/22 Pulmonary Arterial Hypertension (PAH) Agents – Oral Endothelin Receptor Antagonists (ETRAs)
01/06/22 Pulmonary Arterial Hypertension (PAH) Agents – Oral Phosphodiesterase-5 (PDE5)
01/06/22 Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Inhaled
01/06/22 Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Injectable
01/06/22 Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Oral
02/17/22 Ranexa® Clinical Edit
11/18/21 Reblozyl Clinical Edit
12/09/21 Respiratory Monoclonal Antibodies PDL
10/14/21 Retinoids – Topical PDL
11/18/21 Second Generation Sulfonylureas PDL
04/07/22 Sedative Hypnotics PDL
05/05/22 Selzentry® (Maraviroc)
01/20/22 Sickle Cell Disease Clinical Edit
04/07/22 Skeletal Muscle Relaxants PDL
05/26/22 SNRI Clinical Edit
10/14/21 Sodium - Glucose Co - Transporter 2 (SGLT2) PDL
04/07/22 Somatostatin Analogs PDL Edit
04/21/22 Spinal Muscular Atrophy (SMA) Clinical Edit
07/22/21 Spravato® Clinical Edit
01/20/22 SSRI Clinical Edit
01/06/22 Statins (HMG Co-A Reductase Inhibitors) and Combination Products PDL
01/06/22 Sympatholytic Agents PDL
10/14/21 Synagis® Clinical Edit
07/22/21 Systemic Antifungals Clinical Edit
10/14/21 Targeted Immune Modulators, IL17 Receptor Antagonists PDL
05/19/22 Targeted Immune Modulators, IL23-12 Inhibitors PDL
10/14/21 Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL
10/14/21 Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL
10/14/21 Targeted Immune Modulators, Select Agents PDL
12/09/21 Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL
11/18/21 Tepezza Clinical Edit
10/14/21Tetracyclines PDL
10/14/21 Thiazolidinediones & Combination Agents PDL
10/14/21 Thromobocytopenia Treatment Agents PDL
10/28/21 Tolvaptan Clinical Edit
04/07/22 Tramadol - Like Agents PDL
04/07/22 Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit
02/03/22 Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit
01/06/22 Triglyceride Lowering Agents PDL
07/01/21 Ulcerative Colitis Oral Agents PDL
07/01/21 Ulcerative Colitis - Rectal PDL
10/14/21 Urinary Tract Antispasmodics PDL
10/14/21 Vaginal Antibiotics PDL
10/21/21 Verquvo Clinical Edit
05/13/21 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors PDL Edit
02/03/22 Xcopri Clinical Edit
11/18/21 Zokinvy Clinical Edit
11/04/21 Zometa® (zoledronic acid)
07/22/21 Zulresso Clinical Edit