On November 22, 2022, HHSC will revise the clinical prior authorization criteria for calcitonin gene-related peptide (CGRP) antagonist prophylaxis, including the following:
- Separating the renewal criteria set from the initiation of therapy. The renewal criteria steps will include:
- Checking for a diagnosis of severe hepatic impairment in the last 365 days or a diagnosis of severe renal impairment or end-stage renal disease in the previous 365 days.
- Therapy with a strong CYP3A4 inhibitor in the last 90 days or therapy with an organic-anion-transporting polypeptide (OATP) inhibitor in the last 90 days.
- Concurrent therapy with other CGRP antagonists for prophylaxis of migraines.
- Correcting the logic setup for Nurtec ODT to go through step 6 (recommended dosing guidelines for prophylaxis)
- Increasing the prior authorization approval duration to 365 days
HHSC does not require this clinical prior authorization for managed care organizations (MCOs). The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO's prior authorizations and how those authorizations relate to those used for processing fee-for-service Medicaid claims. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO's list of clinical prior authorizations.