Clinical edits, along with the Preferred Drug List (PDL), help ensure access to care through the therapeutically prudent use of pharmaceuticals and optimize the use of program funds.
About Clinical Edits
Clinical edits check a client’s Medicaid medical and drug claims histories to help determine whether the information on file indicates that the client’s medical condition matches the edit criteria for dispensing the requested drug without need of additional prior authorization. The edits are based on evidence-based clinical criteria and nationally recognized peer-reviewed information.
New edits for medications for both Medicaid nursing home clients and for the general Medicaid population will be phased in over time. The Drug Utilization Review Board meets quarterly to determine criteria for retrospective and prospective reviews. Feedback on proposed edits comes from the Drug Utilization Review Board, the Texas Medical Association, and other stakeholders.
Resources for prescribers are available for requesting Prior Authorization for Medicaid clients enrolled in a managed care plan.
How the edits work
- HHSC will establish clinical criteria by which recipients will be able to receive certain products. The criteria may include age, diagnosis from medical history, or inferred diagnosis from prescription claims history.
- When a pharmacy submits a Medicaid claim for a product subject to a clinical edit, the client’s available medical and prescription drug claims histories will be reviewed to determine whether the information shows that the client's condition meets the established criteria.
- If the client’s medical and claims histories demonstrate the criteria are met, the claim will be approved.
- Federal and Texas law required that a 72-hour emergency supply of a prescribed drug be provided when a medication is needed without delay and prior authorization is not available. This rule applies to any drug that is affected by a clinical edit or non-preferred drug that would need the prescriber’s prior approval.
Medicaid edits, performed by Texas PA Call Center
If the client's medical and claims histories do not meet the criteria, the pharmacy will receive a message indicating that the prescriber needs to call the Texas Prior Authorization Call Center. The prior authorization process is similar to the process already established for the preferred drug list.
If clinical edit criteria are unavailable, please contact the HID Technical Helpdesk at 334-321-0177.
- Actiq® Lozenges
- Aliskiren-Containing Agents (Except Valturna)
- Amitiza (Lubiprostone)
- Anticonvulsant agent (Gabapentin)
- Anxiolytics and Sedatives/Hypnotics (ASHs)
- Antiemetics/5HT3 Receptor Antagonists & Aprepitant
- Carisoprodol Overuse
- COX-2 Inhibitors
- Dextromethorphan Overutilization
- Drug Regimen Optimization
- Duplicate Therapy
- Duragesic (Fentanyl Transdermal) Transdermal
- Growth Hormone Products
- Kalydeco (effective 4/30/13)
- Ketorolac (Toradol)
- Opiate Overutilization
- Oxycontin (Narcotic Analgesic)
- Promethazine Utilization, Age < 21
- Suboxone (effective 4/23/13)
- Topical Immunomodulators
1 Clinical edits that must be performed for clients enrolled in managed care. All other clinical edits listed may be implemented by managed care plans. Members should verify with their plans which clinical edits apply.
Medicaid edits, performed by Vendor Drug
Prior approval requests are submitted by the prescribing physician. Please complete all sections of the form or document the reason why information is not available. Incomplete forms will be returned with no action taken. Please date and sign the form and then submit by fax to 512-491-1962.
- Anorexiants (patients of age 21 and over must have a diagnosis that is not for weight loss)
- Growth hormone
- Orlistat (Xenical®)