All MO HealthNet Providers

Third Party Vendor Requesting Drug Prior Authorization

MO HealthNet does not accept drug prior authorization requests from third party vendors including, but not limited to, CoverMyMeds and ZAPPRX. All requests must originate from the prescriber’s office or pharmacy. Additionally MO HealthNet will not provide any participant or claims information to third party vendors nor accept information or documentation from a third party vendor. Providers may contact Pharmacy Administration at (573) 751-6963 if they have questions.

NADAC Pricing Inquiries

Providers may contact the NADAC Help Desk for support of the NADAC survey, to request review of a NADAC rate, or to provide notification of recent drug price changes not reflected in posted NADAC files.

he NADAC Help Desk may be contacted through the following means:

Participants with Other Insurance Coverage

When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance, which includes Medicare Part C plans, in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.

Reimbursement Issues – Pricing Inquiry Process

MO HealthNet providers billing pharmacy claims with reimbursement issues must contact Pharmacy and Clinical Services at (573) 751-6963 prior to dispensing. Reimbursement will be reviewed and if MO HealthNet determines a pricing update is needed, it will be made effective the date of review. If additional review is necessary, the provider must submit the MAC Pricing Inquiry Worksheet. The worksheet may only be submitted when instructed by MO HealthNet and only for the drug(s) specified.

Immunizations for Dual Eligible Participants

MO HealthNet providers billing vaccines for dual eligible participants shall bill Medicare for all vaccines. Vaccine coverage under Medicare Part B includes the pneumococcal, influenza, and Hepatitis B vaccines for individuals at high or intermediate risk, and vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. Other vaccines not covered by Part B are covered by Medicare Part D (pharmacy benefit). When a provider cannot bill the Part D plan directly, the vaccine should be dispensed at a pharmacy.

Aetna Inpatient Care

Consistent with the Managed Care health plan contract, all participants enrolled with Aetna Better Health of Missouri (Aetna) will be transitioned to a new Managed Care health plan effective May 1, 2017. However, for Aetna participants in an inpatient hospital setting that will extend beyond April 30, 2017 coverage will continue under Aetna until discharged. The MO HealthNet Division is asking that providers, participants or the Managed Care health plans contact the following with the admission date and/or the discharge date:

Managed Care Goes Statewide on May 1, 2017

Effective May 1, 2017, the MO HealthNet Managed Care program is offered statewide to all 114 counties and the City of St. Louis. Approximately 240,000 participants, who previously were enrolled in the MO HealthNet Fee-For-Service (FFS) program, are transitioned to a Managed Care health plan. These new Managed Care participants join about 500,000 existing Managed Care participants, amounting to an estimated 740,000 Missourians in the Managed Care program.

Subscribe to All MO HealthNet Providers