List of Drugs for Which Prior Authorization Is Required and Drugs Excluded from Coverage Under the MO HealthNet Pharmacy Program

PURPOSE: This rule establishes a listing of drugs and categories of drugs for which prior authorization is required in order for them to be reimbursable and for which reimbursement is not available under the MO HealthNet Pharmacy Program. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Exclusions—As used in section 208.152.1(12), RSMo, any “abortifacient drug or device” includes: mifepristone when used to induce an abortion; misoprostol when used to induce an abortion; manual vacuum aspirator (MVA) when used to induce an abortion; or any drug or device approved by the federal Food and Drug Administration (FDA) that the FDA has found on or after the effective date of section 208.152.1(12), RSMo, that is intended to cause the destruction of an unborn child as defined in section 188.015, RSMo. (2) Exclusions—As specified in the Social Security Act, Section 1927(d)(1)(B), states may exclude or otherwise restrict coverage of certain covered outpatient drugs. Section 1927(d)(2) of the Social Security Act provides a listing of the categories of drugs that states may exclude. Drugs included on this list may be excluded from coverage entirely or restricted by diagnosis as determined by the state. (3) As specified in Section 1927(d)(1) of the Social Security Act, states may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of Section 1927(d)(5) of the Social Security Act. (4) List of drugs or categories of drugs for which prior authorization is required for certain specified indications, and those which are excluded from reimbursement through the MO HealthNet Pharmacy Program shall be made available through— (A) MO HealthNet provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/manuals/, September 27, 2018. This rule does not incorporate any subsequent amendments or additions; (B) Provider Bulletins, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dss.mo.gov/ mhd/providers/pages/bulletins.htm, September 27, 2018. This rule does not incorporate any subsequent amendments or additions; or (C) Forms, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/ manuals/presentation/forms.jsp, September 27, 2018. This rule does not incorporate any subsequent amendments or additions. (5) The division reserves the right to effect changes in the list of drugs for which prior authorization is required and for which reimbursement is not available by amending this rule. AUTHORITY: sections 1.205, 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021.* Original rule filed Dec. 13, 1991, effective Aug. 6, 1992. Amended: Filed May 15, 1992, effective Jan. 15, 1993. Amended: Filed March 1, 1996, effective Oct. 30, 1996. Amended: Filed May 27, 1999, effective Dec. 30, 1999. Emergency amendment filed Nov. 21, 2000, effective Dec. 1, 2000, expired May 29, 2001. Amended: Filed June 29, 2000, effective Feb. 28, 2001. Emergency amendment filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended: Filed June 11, 2002, effective Jan. 30, 2003. Amended: Filed Jan. 16, 2007, effective July 30, 2007. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Sept. 27, 2018, effective May 30, 2019. Emergency amendment filed Oct. 21, 2021, effective Nov. 4, 2021, expired May 2, 2022. Amended: Filed Oct. 21, 2021, effective April 30, 2022. *Original authority: 1.205, RSMo 1986; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.