Clinical Prior Authorizations Updates and Implementations for Fee-For-Service

On July 27, 2023, HHSC will implement Fee-For-Service updates for Cytokine and CAM Antagonists, Pulmonary Hypertension Agents, and Topical Immunomodulators clinical prior authorizations. Additionally, HHSC will revise the Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis prior authorization criteria.

The implementation will include the following updates:

  • Cytokine and CAM Antagonists:
    • Adding the prior authorization criteria for Sotyktu as approved by the Drug Utilization Review (DUR) Board in April 2023
    • Changing the subheading for the Cibinqo Dosing Guideline table mentioned in step 12, page 18, from “Recommended Dosing Table” to “Maximum Recommended Dose”
    • Adding the maximum recommended dose for Cytochrome P450 2C19 (CYP2C19) poor metabolizers to the table on page 18
    • Adding generic code numbers (GCNs) for Amjevita (a Humira biosimilar product) to the Humira and Biosimilar to the Drugs Requiring Prior Authorization table on page 34 generic code numbers (GCNs): 42639, 42637, 42592
  • Pulmonary Hypertension Agents:
    • Adding GCNs for epoprostenol (33243, 30168) and Orenitam ER (43521).
  • Topical Immunomodulators:
    • Adding a check for the application site for Elidel and Protopic 0.3% to step number 2, pages 4 and 29
    • Updating the approval timeframe for Opzelura to 180 days

As a reminder, HHSC will implement Qulipta in the CGRP Antagonists, Prophylaxis prior authorization, on June 27 for fee-for-service. For the latest version of the criteria guide please click here: CGRP Antagonists, Prophylaxis.

These clinical prior authorizations are optional for MCOs. The Pharmacy Clinical Prior Authorization Assistance Chart shows which clinical prior authorizations each MCO uses and whether the MCO uses all or some of the steps in the prior authorization evaluation process. This chart is updated quarterly. Providers can refer to the MCO Resources page for links to each MCO's list of clinical prior authorizations.