HHSC reviewed the following clinical prior authorization criteria guides and made the updates shown below. These clinical prior authorizations are optional for the MCOs. HHSC will notify providers when we implement any of these prior authorizations for Medicaid fee-for-service.
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 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.
Anxiolytics/Sedatives/Hypnotics
Clinical prior authorization criteria guide (PDF)
Ramelteon
- Corrected step 4 in the Ramelteon criteria logic and diagram.
Diazepam
- Added generic code numbers (GCN) for diazepam (45092, 14210) to the prior authorization table.
Cytokine and CAM Antagonists
Clinical prior authorization criteria guide (PDF)
Amjevita
- Added generic code numbers (GCNs) for Amjevita (42639, 42637, 42592, 54007).
- Updated Humira criteria logic and logic diagram to include Amjevita.
- Added diagnosis of Crohn's disease in adults to Rinvoq.
- Added diagnosis of uveitis for Amjevita.
- Corrected criteria logic for diagnosis of ulcerative colitis for Amjevita.
Multiple Sclerosis
Clinical prior authorization criteria guide (PDF)
Aubagio
- Added GCNs for teriflunomide (33259, 33262) to drug table.
Omega-3 Fatty Acids
Clinical prior authorization criteria guide (PDF)
Vascepa (icosapent ethyl) 500 mg
- Added GCNs for Icosapent Ethyl (33238, 42365).
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
Clinical prior authorization criteria guide (PDF)
Austedo (Deutetrabenazine)
- Added GCNs for Austedo XR (53736, 53737, 53738) to drug table.