Frequently Asked Questions

Does MO HealthNet now have a restrictive formulary?

The MO HealthNet fee for service program has a preferred drug list (PDL). This means the agency solicits supplemental rebates from manufacturers. That economic information will be paired with evidence based clinical information to arrive at preferred drug(s) in each functional therapeutic class. Each drug class on the PDL is reviewed annually. Providers are encouraged to visit the agency’s Web site for the most current information.

What does "Preferred Drug" mean?

A preferred drug is the agent in each functional therapeutic class that the agency would like prescribers to use in beginning therapy. Mo HealthNet will continue to reimburse for all medications whose manufacturers have entered into the federal rebate program (as required by law). Agents other than the preferred product(s) may be approved on the basis of medical necessity at any time. Non-preferred agents may be transparently approved through the agency’s SmartPAsm program after a trial of preferred agents paid for by MO HealthNet. Please see the approval criteria on the Pharmacy Clinical Edit and Preferred Drug List Documents page.

Where can I get additional information on the program and keep up with the changes?

The Pharmacy and Clinical Services Unit posts all program material on the agency’s Web site. A pharmacy specific Web site is also available at . Additionally, you may subscribe to the agency's E-mail updates.

How may I be involved in the process?

The preferred drugs are chosen through a process defined by The agency’s two advisory groups, the Drug Prior Authorization Committee and the Drug Use Review Board have quarterly meetings. The agendas are posted on the Web sites and open to the public. You may also address specific questions or concerns directly to the Pharmacy and Clinical Services Unit.

Pharmacy and Clinical Services
Department of Social Services, MO HealthNet Division
Post Office Box 6500
Jefferson City, MO 65102-6500

How are claims screened and what does "transparently screened" mean?

Virtually all pharmacy claims are processed online real-time. The claims are juried against other drug claims, participant diagnoses, and prior participant procedure claims. Clinical rules (edits) are established that look for those data elements, thus eliminating many calls for providers. Claims meeting approval criteria require no call and occur over seventy-five percent of the time. Claims not meeting criteria are rejected and must be overridden by the call center if necessary.

Is cost the only consideration in the choice of preferred drugs?

No. All edits are based first on medical evidence, and then net system cost is considered in development of the PDL.

What sources of medical information are used to determine preferred drug choice?

The agency uses the following sources of medical information:

  • Clinical information provided by the manufacturer
  • Evidence-based reviews developed by the Evidence-based Practice Center of Oregon Health Sciences University
  • University of Missouri-Kansas City Drug Information Center
  • Conduent State Health, LLC clinical staff
  • MHD clinical staff
How do I request a non-preferred agent for a patient?

A prescriber or pharmacy may call the agency hotline at 800-392-8030 or fax the request to 573-636-6470. Hotline calls are completed within minutes and approvals immediately available in the point-of-sale system. Fax requests are usually completed in hours with a maximum of 24 hours during the normal work week.

Can I expect delays at the call center or in obtaining approval?

The average wait time at the call center is less than 2 minutes. During peak times in the early and late afternoon wait times may be longer. The unit monitors the call center wait times, and reacts by placing more technicians on the line at peak times to eliminate delays.

What if I don't agree with the call center determination?

If a provider feels the call center determination was clinically unsound they are encouraged to contact the Pharmacy and Clinical Services Unit clinical staff at 573-751-6963. If there is still disagreement, the participant has a right to appeal the determination through the Fair Hearings Process, by writing the MO HealthNet Division Participant Services Unit (PSU), PO Box 3535, Jefferson City, MO 65102-3535 to request a hearing. The Participant Services Unit may also be called toll free at 1-800-392-2161 or 573-751-6527 at the caller’s expense. The participant must contact RSU within 90 days of the date of the denial letter if they wish to request a hearing.

The goal of the MO HealthNet Division and Clinical Services Unit is to provide clinically sound medication choices for MO HealthNet participants. Those choices are based on medical evidence and net program cost. The unit welcomes your questions, concerns and feedback. The unit appreciates the provider commitment and support in servicing Missouri’s most vulnerable citizens.