MedicaidPrior AuthHigh impact
Opioids and CGMs may not need a PA
Missouri Medicaid (MO HealthNet)·MO · Pain Management, Endocrinology, Family Medicine +2 more·Provider Notice
Effective date
Feb 27, 2023
We identified it
Jun 26, 2026
Summary
MO HealthNet eliminates prior authorization requirements for opioid prescriptions under 50 MME per day and for Dexcom CGM devices for insulin-dependent patients. Opioid-naive patients still require a 7-day fill prior to full 30-day prescriptions. Dexcom CGM auto-approves at pharmacy for eligible participants with recent rapid/short-acting insulin fills, requiring no additional paperwork from providers.
Action Required
Immediately (effective 02/27/2023): Billing team and providers must update internal workflows and billing system rules to reflect elimination of prior authorization requirements for: (1) opioid prescriptions <50 MME/day for MO HealthNet patients, and (2) Dexcom CGM for insulin-dependent participants. Update prior auth submission lists and encounter templates to remove these items. Pharmacy staff should be notified that Dexcom CGM will auto-approve without provider documentation. For opioid-naive patients, ensure pharmacy applies 7-day fill restriction before 30-day fills regardless of MME. Failure to remove unnecessary prior auth requests may delay claim processing and patient access to medications.