Medicaid Non-preferred Prior Authorization

HHSC arranges the PDL by drug class, and it contains a subset of many, but not all, drugs found on the Medicaid formulary. Preferred drugs on the PDL are selected using criteria based on safety, efficacy and cost, and are available without prior authorization unless there is a clinical prior authorization associated with the drug. Non-preferred drugs require a PDL prior authorization. Some preferred drugs may also require clinical prior authorization.

The PDL Criteria Guide explains the criteria used to evaluate the non-preferred prior authorization requests.

MCOs use the same non-preferred prior authorization criteria requirements but may have non-preferred requirements on a limited set of home health supplies provided by Medicaid-enrolled pharmacies.

The DUR board makes PDL recommendations each quarter and submits them for review to the HHSC Executive Commissioner. The biannual PDL incorporates the commissioner’s decisions on the schedule identified below.

Board Meets / PDL Recommendations Published PDL Published
January July
April July
July January
October January

Refer to the VDP website DUR Board Agenda and Documents page (txvendordrug.com/resources/drug-utilization-review-board/meeting-agendas-and-documents) for each board meeting's recommendations and the HHS-approved decisions.

HHSC organizes the PDL by therapeutic class, identifying the preferred agents, non-preferred agents, and any prior authorization criteria. The PDL identifies drugs requiring clinical prior authorization with a hyperlink to the clinical criteria document.

Refer to the VDP website Preferred Drug page (txvendordrug.com/formulary/prior-authorization/preferred-drugs) to review the latest edition of the PDL.

The Formulary search (txvendordrug.com/formulary/formulary-search) identifies drugs requiring non-preferred prior authorization. Users can select the "PDL PA Required" check-box for the list of drugs.