Managed Care Clinical Prior Authorization

MCOs must implement specific clinical prior authorizations for clients enrolled in Medicaid managed care. Usage of all other clinical prior authorizations will vary between MCOs at the discretion of each MCO. MCOs cannot establish a clinical prior authorization for a drug without approval by HHSC, and no prior authorization can be more stringent than what was approved.

The Clinical Prior Authorization Assistance Chart shows the prior authorizations used by each MCO and those used for traditional Medicaid. Pharmacy providers should contact the client's specific MCO for details.

Refer to the Prior Authorization section for more about clinical prior authorization criteria.