Mo. Code Regs. tit. 13 § 70-20.031
Current through Register Vol. 49, No. 23, December 2, 2024
Section 13 CSR 70-20.031 - List of Drugs for Which Prior Authorization Is Required and Drugs Excluded from Coverage Under the MO HealthNet Pharmacy ProgramPURPOSE: This amendment updates language in section (1) to add exclusions and definition for abortifacient drugs or devices, and revises sections (2) and (5).
(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/presen-tation/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 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. Amended by Missouri Register April 1, 2019/Volume 44, Number 7, effective 5/31/2019Amended by Missouri Register March 15, 2022/Volume 47, Number 6, effective 4/30/2022*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, amended 2007.