Medicaid Prior Authorization

Prior authorization is a process used to determine if a prescribed procedure, service, or medication is necessary, appropriate, and not likely to cause adverse effects. Prescribing providers must submit an authorization request for the drug before Medicaid pays the claim.

Each MCO administers pharmacy prior authorization services for clients enrolled in managed care. The Texas Prior Authorization Call Center manages prior authorizations for clients in Medicaid fee-for-service.

All clients enrolled in Medicaid adhere to the same formulary. Some drugs on the formulary may require prior authorization. There are two types of prior authorizations impacting a covered Medicaid outpatient drug on the formulary

• Clinical
• Non-preferred

Some drugs or drug classes are subject to both non-preferred and clinical prior authorizations.

The Texas Drug Utilization Review (DUR) Board reviews classes of drugs every quarter and recommends drugs for preferred or non-preferred status on the Texas Medicaid Preferred Drug List (PDL), and establishes recommendations for clinical prior authorizations.