Update for Specialized Formulas

Already effective September 15, 2026 (Pathway 1) and October 21, 2026 (Pathway 2): (1) Billing team must verify whether the practice has implemented dual billing pathways and confirm current applicability with MO HealthNet. (2) For specialized formulas in children age 5 and under previously covered by WIC, update billing procedures to submit pharmacy point-of-sale claims with the product's 11-digit NDC through eMOMED or standard pharmacy adjudication; these claims are processed under MO HealthNet Fee-for-Service Pharmacy Program. (3) For all other specialized formulas, medical foods, and enteral nutrition products (including products for participants over age 5 and modular supplements), continue billing DME claims using the listed HCPCS B-codes (B4149–B4162) to the appropriate payer: directly to the participant's Managed Care health plan if enrolled in MO HealthNet Managed Care, or directly to MO HealthNet via eMOMED (CMS-1500 or 837P format) if carved out or under traditional Fee-for-Service. (4) Confirm that Managed Care health plans have been instructed to maintain B-codes active and honor previously granted Prior Authorizations; contact individual Managed Care plans for plan-specific requirements. (5) Verify current status of the active list of Covered Specialized Infant Formulas online and ensure DME providers dispensing formulas on Pathway 1 understand they are not required to separately enroll as MO HealthNet pharmacy providers. (6) Note that these items remain non-covered for adults age 21 and older except through the MO HealthNet Exceptions process.