Missouri HealthNet Managed Care Pharmacy Program Overview
Missouri Medicaid members receive pharmacy benefits through the State’s MO HealthNet Fee-for-Service Pharmacy program. The pharmacy benefit is not administered by the Managed Care Plan.
The pharmacy services managed through the State’s MO HealthNet Fee-for-Service Pharmacy program includes all pharmacy services administered on an outpatient basis, including but not limited to:
- physician administered drugs, non-oral contraceptives, covered over the counter (OTC) products, covered tobacco cessation products, covered diabetic testing supplies, and all drugs dispensed by the outpatient department of a hospital, clinic or pharmacy.
For pharmacy services provided in a home health setting, the State’s MO HealthNet Fee-for-Service Pharmacy program will cover the pharmacy service when billed on a pharmacy claim form including all of the appropriate information such as, but not limited to, the National Drug Code (NDC), quantity, and dosage form.
Managed Care Plan Responsibilities
The Managed Care Plan will be responsible for:
- Pharmacy claims billed as part of an inpatient hospital admission.
- VFC vaccine administrations must be billed to the Managed Care Plan and not MO HealthNet.
- The home health visit and all supplies incidental to the administration of the medication in a home health setting.
Other Important Information
Check for frequently updated MO HealthNet Fee-for-Service Pharmacy Program information at http://dss.mo.gov/mhd/cs/pharmacy/pages/frequpdat.htm
Drug Prior Authorizations
- For drug prior authorizations, call 800-392-8030.
- Fax in drug prior authorization requests to: 573-636-6470.
Contact the State’s Missouri HealthNet Pharmacy Help Desk at 573-751-6963 for questions on pharmacy claims .
Opioid Programs and Resources
Please review the Opioid Programs and Resources - Community Plan (Medicaid) section.