PURPOSE: This rule establishes a listing of excludable drugs and categories of drugs for which prior authorization is required in order for them to be reimbursable 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. (1) Permissible 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 are permissible for exclusion. Drugs included on this list may be excluded from coverage entirely or restricted by diagnosis as determined by the state.
2. (2) 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.
3. (3) List of drugs or categories of excludable drugs which are restricted to require prior authorization for certain specified indications shall be made available through the Department of Social Services, MO HealthNet Division website at dss.mo.gov/mhd, provider bulletins, and updates to the provider manual 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, October 15, 2013. This rule does not incorporate any subsequent amendments or additions. The division reserves the right to affect changes in the list of excludable drugs for which prior authorization is required by amending this rule.

AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013.* 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. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, amended 2007.