Fee-For-Service Clinical Prior Authorization Implementation Delayed

Published on

This is an update to the notice "HHSC To Implement Clinical Prior Authorizations For Fee-For-Service on Oct. 31" published on Aug. 31.

HHSC will implement the Antipsychotics clinical prior authorization criteria (PDF) for fee-for-service on Jan. 16, 2024. Changes to the Antipsychotics clinical prior authorization include:

  • For the drug Lybalvi:
    • Added criteria as approved by the DUR Board in Oct. 2021
  • For the drug Rexulti:
    • Updated age to 13 years and older in patients with Schizophrenia
    • Updated age to 18 years and older in patients with Major Depressive Disorder
    • Added diagnosis for agitation associated with dementia due to Alzheimer’s disease

HHSC will announce the implementation dates for the following clinical prior authorization criteria at a later date:

  • Amyotrophic Lateral Sclerosis (ALS) Agents
    • New criteria
  • Fecal Microbiota Transplantation (FMT) Agents
    • New criteria
  • Veozah
    • New criteria

The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO's prior authorizations and how these authorizations relate to those that are used for processing Medicaid fee-for-service claims. This chart is updated quarterly. Providers can use the MCO Search to find links to each MCO’s list of clinical prior authorizations.