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
Psoriasis Agents, Topical PDL Edit
Psychotropic Medications Polypharmacy Clinical Edit || Psychotropic Medication Polypharmacy Prior Approval 2575-033
Pulmonary Arterial Hypertension (PAH) Agents, Endothelin Receptor Antagonists (ETRAs) PDL
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Inhaled PDL
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Injectable PDL Edit
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Oral PDL Edit
Pulmonary Arterial Hypertension (PAH) Agents,Phosphodiesterase-5 (PDE5) and Soluble Guanylate Cyclase (SGC) Stimulators PDL Edit
Ranolazine Clinical Edit
Reblozyl Clinical Edit
Retinoids, Topical PDL Edit
RSV Prophylaxis - Pediatric Clinical Edit || Synagis Prior Authorization 2575-047
Scenesse Clinical Edit
Sedative Hypnotics PDL Edit
SSRI Step Therapy Clinical Edit
Selzentry Clinical Edit
Serotonin and Norepinephrine Reuptake Inhibitors Clinical Edit
Sickle Cell Disease Clinical Edit
Skeletal Muscle Relaxants PDL Edit
Skyclarys Clinical Edit
Skysona Clinical Edit
Sodium-Glucose Co-Transporter (SGLT) Inhibitors & Combination Agents PDL Edit
Sohonos Clinical Edit
Somatostatin Analogs PDL Edit
Spinal Muscular Atrophy Clinical Edit
Spravato Clinical Edit
Statins (HMG-CoA Reductase Inhibitors) and Combinations PDL Edit
Sulfonylurea Agents, Second Generation PDL Edit
Sympatholytics PDL Edit
Systemic Enzyme Inhibitors, FGFR Inhibitors PDL Edit
T-Cell Immunotherapy Clinical Edit (formerly CAR-T Cell Therapy)
Targeted Immune Modulators, IL-23 Inhibitors and IL-23/IL-12 Inhibitors PDL Edit
Targeted Immune Modulators, Interleukin (IL)-17A Antibody/IL-17 Receptor Antagonists PDL Edit
Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL Edit
Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL Edit
Targeted Immune Modulators, Lupus Agents PDL Edit
Targeted Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies PDL Edit
Targeted Immune Modulators, Select Agents PDL Edit
Targeted Immune Modulators, Small Molecule Janus Kinase (JAK) Inhibitors Clinical Edit
Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL Edit
Tepezza Clinical Edit