Preferred Drug List & Utilization Managment Edits

Pharmacy Clinical Edits and Preferred Drug Lists

Pharmacy Program staff work with the MO HealthNet’s Pharmacy Advisory Committees, the University of Missouri-Kansas City School of Pharmacy Drug Information Center, the Oregon Evidence-Based Drug Research Consortium, and contractors to perform evidence-based reviews and develop product recommendations for utilization management (UM) and preferred drug list (PDL), which includes both drug and non-drug products. The clinical information is paired with a fiscal evaluation and developed into edit criteria. The UM program and PDL is vital to the utilization management strategy for point-of-sale and physician-administered drugs available via the Fee-For-Service benefit. An effectively and efficiently managed Pharmacy Program will provide savings and promote clinical care and prescribing habits based on best practices.

Implementation Schedule PDL/DSP Searchable Database Preferred/Non-Preferred Products Drug Prior Authorization Forms

Effective Date Pharmacy Clinical Edit and PDL Description Upcoming Policy Changes
Corlanor Clinical Edit
Corticosteroids & Rhinitis Agents, Intranasal PDL Edit
Corticosteroids, Ophthalmic “Soft” PDL Edit
Corticosteroids, Oral Inhaled PDL Edit || Asthma SMART Therapy
Corticosteroids, Topical PDL Edit
Cough and Cold Preparations Fiscal Edit
Covered OTC List
Covered Prenatal Vitamins
Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL Edit
Crysvita Clinical Edit
Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors PDL Edit
Cystic Fibrosis Modulators Clinical Edit
Daybue Clinical Edit
MO HealthNet Preferred Diabetic Supplies
Diabetic Supply Quantity Fiscal Edit
Diagnosis Code Required Policy Edit
Direct Renin Inhibitors & Combinations PDL Edit
Dose Opt Fiscal Edit
DPP-IV Inhibitors & Combination Agents PDL Edit
Duchenne Muscular Dystrophy Clinical Edit
Electrolyte Depleting Agents, Phosphate Lowering PDL Edit
Electrolyte Depleting Agents, Potassium Lowering PDL Edit
Emsam Clinical Edit
Encelto Implant Clinical Edit
Entresto Clinical Edit
Enzyme Deficiency Clinical Edit
Epidermolysis Bullosa Clinical Edit
Epinephrine Self-Administered Agents PDL Edit (Formerly Epinephrine Self-Injectable Agents)
Erythropoiesis Stimulating Agents PDL Edit
Extended Supply Fiscal Edit
Fabry Disease Clinical Edit
Familial Chylomicronemia Syndrome Clinical Edit
Fibromyalgia Agents PDL Edit
Filspari Clinical Edit
Fluoroquinolones, Ophthalmic PDL Edit
Fluoroquinolones, Oral PDL Edit
Fluoroquinolones, Otic PDL Edit
GABA-A Modulators for Postpartum Depression Clinical Edit
Gamifant Clinical Edit
Gene Therapies for Sickle Cell Disease and Beta-Thalassemia PDL Edit