HHSC To Implement Clinical Prior Authorizations For Fee-For-Service on Oct. 31

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HHSC will make the changes to the clinical prior authorization criteria outlined below on Oct. 31. These clinical prior authorizations are optional for the MCOs. The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO's prior authorizations and how these authorizations relate to those used for processing fee-for-service Medicaid claims. This chart is updated quarterly. Providers can use the MCO Search to find links to each MCO's list of clinical prior authorizations.

Amyotrophic Lateral Sclerosis (ALS) Agents

ALS Agents criteria guide (PDF)

  • New Criteria

Antipsychotic Agents

Antipsychotic Agents criteria guide (PDF)

  • Added generic code numbers (GCNs) to the drug table on page 2:
    • Asenapine (GSNs: 27528, 38479, 21636)
    • Lurasidone (GSNs: 31226, 29366, 35192, 29367, 33147)
  • Added generic code numbers (GCNs) to the drug table on page 8:
    • Invega Hafyera (GSN: 50891)
    • Invega Sustenna (GSN: 27414)
    • Abilify Asimtufii (GSNS: 54058, 54059)
    • Uzedy (GSNs: 54098, 54099, 54104, 51479, 54105, 54106, 54107)
  • Removed GCNs from the drug table on page 2:
    • Fazaclo (product discontinued)
  • Risperdal M tablet (product discontinued)  

Lybalvi 

  • Added criteria as approved by the DUR Board in Oct. 2021

Rexulti 

  • Updated age to 13 years and older with patients with Schizophrenia
  • Updated the age to 18 and higher in patients with Major Depressive Disorder
  • Added diagnosis for agitation associated with dementia due to Alzheimer’s disease 

Anxiolytics and Sedative/Hypnotics (ASH)

ASH criteria guide (PDF)

  • Added generic code numbers (GCNs) to the drug table on page 10:
    • Diazepam injection (GCNs: 45092, 14210)
  • Added GCNs to the table on page 23
    • Quviviq (GSNs: 51785, 51787)
  • Added GCN to the table on page 38
    • tasimelteon (GSN: 36068)
  • Revised the check for short-term therapy for procedures to read, ‘Is the incoming request for less than or equal to 5 units?’ on all agents except Hetlioz
  • Updated all instances of ‘history of drug abuse’ in criteria logic and logic diagram to ‘history of drug abuse or dependence’
  • Corrected ramelteon logic and diagram (question #4)

Lorazepam 

  • Added criteria to allow for approval without diagnosis for pediatric patients less than two years.
  • Added criteria to allow approval for patients with a diagnosis of nausea and vomiting associated with cancer

Cystic Fibrosis

Cystic Fibrosis criteria guide (PDF)

  • Updated References

Kalydeco

  • Removed age check

Orkambi 

  • Added GCN: 52865 to table on page 15

Trikafta

  • Updated age to two years and older
  • Trikafta (GSN: 54048, 54047)

Cytokine and CAM

Cytokine and CAM criteria guide (PDF)

Amjevita

  • Added diagnosis of uveitis

Cosentyx

  • Corrected age to 2 years and older for psoriatic arthritis 

Kevzara

•    Added diagnosis of polymyalgia rheumatica 

Olumiant

  • Removed check for OAT3 inhibitors
  • Revised check for severe renal impairment (from < 60 mL/min/1.73m3 to < 30 mL/min/1.73m3) per updated prescribing information

Rinvoq

  • Added diagnosis of nr-axSpA in adults
  • Added diagnosis of Crohn’s disease in adults

Skyriz

  • Added diagnosis of Crohn’s disease in adults

Stelara 

  • Updated age to 6 years and older for psoriatic arthritis

Monoclonal Antibody Agents

Monoclonal Antibody Agents criteria guide (PDF)

Dupixent

  • Added diagnosis of eosinophilic esophagitis for clients greater than or equal to 12 years of age
  • Updated age to greater than or equal to six months for patients with atopic dermatitis
  • Added diagnosis of prurigo nodularis for clients greater than or equal to 18 years of age

Fecal Microbiota Transplantation (FMT) Agents

FMT Agents criteria guide (PDF)

  • New Criteria

Gastrointestinal (GI) Motility

GI Motility criteria guide (PDF)

  • Added GCNs to the ‘history of opioid therapy’ table, pages 9
    • Belbuca (GCNs: 39959, 39965, 39966, 39967, 39968, 39969, 39975),
    • Buprenorphine patch (GCNs: 25309, 35214, 25312, 25308, 36946)
    • Butrans (GCNs: 25309, 35214, 25312, 25308, 36946), codeine (16240)
    • Hydrocodone ER (GCNs: 37539, 37541, 37543, 37544, 37545, 37546, 37547)
    • Levorphanol (GCN: 16350)
    • Oxycodone-apap solution (GCN: 70470)
    • Oxycodone (GCNs: 37159, 37162, 37164)
    • Tramadol (GCNs: 99151, 99152, 92069) 
  • Removed GCNs from the ‘history of opioid therapy’ table, page 9, due to discontinuation
    • Avinza (GCNs: 17189, 17192, 17191)
    • Bunavail (GCNs: 36677, 36678, 36679)
    • Duragesic (GCNs: 19203, 24635, 19200, 19201, 19202)
    • Embeda ER (GCNs: 37692, 37685, 37686, 37687, 37688, 37689)
    • Exalgo GCNs: (28427, 22098, 33088, 22056)
    • Ibudone (GCNs: 99371, 22678)
    • Kadian ER (GCNs: 26490, 26494, 26492, 98135, 37534, 33158, 26493, 37535, 97508)
    • Lazanda (GCNs: 27648, 41539, 29146)
    • Opana/Opana ER (GCNs: 27244, 27243, 33916, 33833, 33917, 33918, 33919, 33915, 33832)
    • Reprexain (GCNs: 99371, 16279, 22678)
    • Rezira (GCNs: 92058)
    • Xartemis (GCNs: 36243)
    • Zutripro (GCNs: 30047) 

Ibsrela

  • Added clinical criteria as approved by the DUR Board on July 22, 2022

Linzess

  • Updated criteria to include patients aged 6 to 17 with a diagnosis of functional constipation

Motegrity (prucalopride) 

  • Added clinical criteria as approved by the DUR Board at the July 2019 meeting

Symproic 

  • Added new criteria

Trulance 

  • Added irritable bowel syndrome with constipation as an approved diagnosis 

Glucagon-like Peptide-1 (GLP-1) Receptor Agonists

GLP-1 Agonists criteria guide

Ozempic, Trulicity and Victoza

  • Added check for atherosclerotic cardiovascular disease (ASCVD), Heart Failure (HF), and Chronic Kidney Disease (CKD) without prior oral antidiabetic therapy

Trulicity

  • Updated age to 10 years and older

Omega 3 Fatty Acids

Omega 3 Fatty Acids criteria guide (PDF)

  • Added GCNs for Icosapent Ethyl (33238, 42365)

Sodium-glucose cotransporter-2 (SGLT2) Inhibitors

SGLT2 Inhibitors criteria guide (PDF)

Jardiance, Synjardy and Synjardy XR

  • Updated age to 10 years and older for criteria logic and diagram

Urea Cycle Disorder Agents

Urea Cycle Disorder Agents criteria guide (PDF)

Olpruva

  • Added GCNs: 53445, 53446, 53447, 53448, 53452

Veozah

Veozah criteria guide (PDF)

  • New criteria

Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors

VMAT2 Inhibitors criteria guide (PDF)

  • Added GCNs to the table on page 3
    • Austedo XR (GCNs: 53736, 53737, 53738) 
    • Added GCNs to Step 7 table page 14
    • Aptivus (GCN: 24906) 
    • Vizimpro (40421, 40422, 40423) 
    • Added GCN for armodafinil (98590, 36082, 98592, 98591)
    • Added GCN for armodafinil (98590, 36082, 98592, 98591)
    • Added GCNs to table on page 20
    • armodafinil (98590, 36082, 98592, 98591)
    • Banzel (98836, 29462, 98827)
    • bosentan (14978, 14979)
    • clobazeam (09071, 35026, 09070)
    • dexamethasone (27422, 27400, 27411, 27425, 27424, 27427, 27426, 27428, 27354, 27429, 27412)
    • linezolid (26871)
    • Nuvigil (98590, 36082, 98592, 98591)
    • Onfi (09070, 35026, 09070)
    • Orilissa (45026, 45028),
    • oxcarbazepine (21724, 21721, 21723, 21722),
    • Oxtellar XR (33556, 33557, 33558)
    • Tracleer (43819),
    • Trileptal (21724, 21721, 21723, 21722)
    • Xermelo (43109) 
  • Added GCNs table page 17
    • Added Ingrezza 60mg (49577) to the drug table
    • Zelboraf (30332) 
  • Added GCN to table on page 25 
    • atazanavir (19952, 19953, 97430)
    • itraconazole (49100)
    • Korlym (31485)
    • Prezista (31201, 23489, 99434, 167559, 33723)
    • Reyataz (19952, 19953, 37430, 36647)
    • ritonavir (28224)
    • Tolsura (45848)