Diagnosis Code Requirement on Certain Pharmacy Claims

Diagnosis Code Requirement on Certain Pharmacy Claims

Effective January 25, 2024, the MO HealthNet Division (MHD) began requiring ICD10 diagnosis codes on pharmacy claims for select drugs and drug classes in order to gain further insight into actual real-world utilization of drug products for on and off-label indications. This will allow MHD to potentially improve the transparent processing of pharmacy claims for these select drugs and drug classes.

Asthma Inhaler Update

Asthma Inhaler Update

The MO HealthNet Pharmacy Program has become aware of a nationwide shortage of Asmanex® HFA inhalers. As brand name Flovent HFA® has also been discontinued by the manufacturer, this action has reduced access to maintenance medications for pediatric patients with asthma. In response to these changes in the marketplace, the following temporary changes in the Corticosteroids, Oral Inhaled PDL Edit will be effective 1/25/2024: 

Inhalers Update

Inhaler Update 

Effective for dates of service on and after January 15, 2024, MO HealthNet will no longer allow an exception to the Take Home Drugs and Supplies policy for hospital and clinic providers to bill for an inhaler if the participant is diagnosed with COVID or the participant has been exposed to COVID-19.

RSV Prophylaxis

The MO HealthNet Division (MHD) will begin to review requests for Synagis (palivizumab) effective October 30, 2023.

Due to current supply constraints for the new RSV prophylaxis agent Beyfortus (nirsevimab), MHD will allow up to two doses of Synagis for November and December 2023. Participants who meet the clinical edit requirements, including age restrictions, may receive approval for up to two doses to start the 2023 - 2024 RSV season, depending on the requested date for the initial prior authorization and the current availability of Beyfortus.

Morphine Milligram Equivalent (MME) Factor Update for Hydromorphone, Methadone, and Tramadol

In the CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 | MMWR(link is external), the CDC updated the MME values for oral hydromorphone, methadone, and tramadol. MO HealthNet will begin utilizing these updated MME values effective 9/17/2023 while processing claims.

Vaccines for Children Program – Pharmacy Providers

MO HealthNet pharmacy providers not enrolled in the VFC program cannot administer vaccines to MO HealthNet participants covered under the VFC program. A VFC provider must immunize all MO HealthNet children for VFC vaccines. Through the VFC Program, federally provided vaccines are available at no cost to public and private providers for eligible children ages 0 through 18 years of age. Children that meet at least one of the following criteria are eligible for VFC vaccine:

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