Preferred Drug List & Utilization Managment Edits

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
Gene Therapies for Sickle Cell Disease and Beta-Thalassemia PDL Edit
GI Motility Agents, Chronic PDL Edit
Givlaari Clinical Edit
Glaucoma Agents PDL Edit
Glucagon Agents PDL Edit
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists & Combination Agents Indicated for Diabetes PDL Edit
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Indicated for Obesity PDL Edit
Growth Hormone Agents, Somatropin Short Acting PDL Edit || Growth Hormone Somatropin Agents Prior Authorization
Growth Hormone Releasing Factors, Select Agents PDL Edit
Growth Hormone Somatropin Agents, Long-Acting PDL Edit
HBV Nucleotide Analog Reverse Transcriptase Inhibitors Fiscal Edit
Hemgenix Clinical Edit
Hemophilia Gene Therapy Agents Clinical Edit
Hepatitis-C Agents PDL Edit || Hepatitis C Treatment Prior Authorizaton
Hereditary Angioedema Agents PDL Edit
High Risk Therapy Clinical Edit
Homozygous Familial Hypercholesterolemia (HoFH) Agents PDL Edit
Hospice Fiscal Edit
Imcivree Clinical Edit
Immunoglobulins (IVIG/SCIG) Clinical Edit
Inflammatory Bowel Disease Agents, Oral PDL Edit
Inflammatory Bowel Disease Agents, Rectal PDL Edit
Inhaler Spacers Excessive Therapy Edit
Insulin Pumps – Tubeless Clinical Edit
Insulin, Long Acting PDL Edit
Insulin, Mixed PDL Edit
Insulin, Non-Analogs PDL Edit
Insulin, Rapid Acting PDL Edit
Iron – Injectable Step Therapy Edit
Isturisa Clinical Edit
Joenja Clinical Edit
Journavx Clinical Edit
Kebilidi Clinical Edit
Keratoconjunctivitis Agents PDL Edit
Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit
Lenmeldy Clinical Edit
Leukotriene Receptor Modifiers PDL Edit
Lipotropics, Alternative Agents PDL Edit
Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Non-Oral PDL Edit
Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Oral PDL Edit