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 Missouri Medicaid Pharmacy Program.

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, Division of Medical Services website at www.dss.state.mo.us/dms, provider bulletins, and updates to the provider manual.

AUTHORITY: sections 208.153 and 208.201, RSMo 2000.* 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 filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended: Filed June 11, 2002, effective Jan. 30, 2003.

*Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.