On December 22, 2021, the FDA issued an emergency use authorization (EUA) for Pfizer’s COVID-19 treatment, Paxlovid. Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kilograms) with positive results of direct SARS-CoV-2 testing and who are at high risk for progression to severe COVID-19, including hospitalization or death.
Effective November 1, 2021, MO HealthNet will cover at-home COVID-19 tests through the Fee-for-Service Pharmacy Benefit. MO HealthNet will reimburse the lesser of the MAC rate plus a dispensing fee or the Usual & Customary submitted by the provider. At-home tests must be prescribed by a MO HealthNet provider. MO HealthNet will monitor the use of at-home tests to prevent potential waste. Below are the covered at-home tests, including the MAC price per unit.
Effective October 21, 2021, MO HealthNet will implement a new Extended Supply Fiscal Edit. This new edit requires participants to receive a 90 day supply on select medication. The fiscal edit, including a complete list of medications included in the 90 day supply requirement, can be found on our website at https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm.
The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri outside of the regular RSV season. MHD has considered RSV prophylaxis requests starting in July 2021. Effective September 28th: participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to 6 doses. This includes 1 dose for October and up to 5 doses during the regular Missouri RSV season (November thru April). Previously approved doses given from July through September are not considered to be part of the 6 doses.
The MO HealthNet Division (MHD) is aware of the sustained increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July, August & September. For participants who meet the clinical edit requirements, approval will include up to three doses.
The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorization requests during July & August. For participants who meet the clinical edit requirements, approval will include two doses. For participants who were approved in July the doses will be for July and August, for participants approved in August the doses will be for August and September. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology.
The MO HealthNet Division (MHD) is aware of the increased positivity of RSV virology in the State of Missouri. MHD will consider RSV prophylaxis prior authorizations requests during July. For participants who meet the clinical edit requirements, approval will include two doses. MHD will evaluate the need for additional doses on a month-to-month basis, dependent on RSV virology. Providers with questions may call MO HealthNet at 800-392-8030.
The MO HealthNet Division (MHD) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19").
MHD continues to monitor the Centers for Medicare and Medicaid Services (CMS) guidance related to COVID-19 testing and specimen collection. The tables below list the COVID-19 testing and specimen collection procedure codes MO HealthNet currently covers as well as who can bill each code, effective dates, max units, and rates.
The MO HealthNet Division (MHD) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19").
Effective January 6, 2021, MO HealthNet’s Non-Emergency Medical Transportation (NEMT) vendor for fee-for-service participants changed its name from LogistiCare Solutions, LLC to ModivCare Solutions, LLC as part of a company rebranding initiative. Modiv is Latin for “way”, and reflects the company’s desire to lead innovation and change in terms of how people connect to care. The new name will not change any of the services provided.
Other changes as part of the rebrand include:
