Before requesting prior authorization (PA) from the MO HealthNet Division (MHD) for any medication, please verify whether the participant has any other third-party liability (TPL). Providers must utilize all available third-party benefits, including exploring therapeutic alternatives, pursuing prior authorization through the third-party payer, and utilizing a preferred pharmacy before MHD will consider reviewing PAs for participants with TPL. It is important to remember that obtaining PA approval from MHD does not exempt it from being the payer of last resort.
MHD will review PA requests in cases where third-party payers exclude all therapeutic alternatives from their coverage. These reviews are conducted on a case-by-case basis by Pharmacy Administration, and providers are required to submit documentation of the third-party PA denial along with an appeal of the coverage exclusion. Contact Pharmacy Administration at MHD.PharmacyAdmin@dss.mo.gov or 573-751-6963.
Additionally, dual-eligible participants receive pharmacy benefits through their Medicare Part D plan (PDP). MORx is a secondary payer following the PDP. MORx does not maintain a formulary and only covers prescription drugs already covered by the PDP. If a participant's PDP does not cover a specific medication or denies a prior authorization, MORx will not provide coverage for that medication.