13 CSR 70-20.031 - List of Drugs for Which Prior Authorization Is Required and Drugs Excluded from Coverage 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.
Notes
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