August 17, 2020
VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations. The following opioid prior authorizations are scheduled for revision on Sept. 1, 2020, to align with the uniform opioid policy.
Opioid Policy criteria
The Opioid Policy criteria (PDF) (formerly known as the Morphine Milligram Equivalent [MME] criteria) is revised to comply with the following:
- Opioid naïve is defined as members who have taken opioids for a duration less than or equal to seven days in the prior 60-day period. For opioid naïve patients, Texas Medicaid must require a one-time authorization for:
- An opioid prescription which exceeds a ten-day supply
- A prescription for a long-acting opioid formulation
- A claim in which the total daily dose of opioids exceeds 90 MME
- For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MME. If approved, the authorization is for a six-month duration.
The criteria are mandatory for the MCOs.
Opiate Over-utilization criteria
The Opiate Over-utilization criteria (PDF) implements Sept. 1, 2020. The criteria document was revised to include sickle cell, palliative care, and hospice care diagnosis to question #1 of the criteria logic. This change will align the prior authorization criteria with the new opioid policy.
This clinical prior authorization is optional for the MCOs to implement. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly.