HHSC Updates Clinical Prior Authorization Criteria Guides

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HHSC reviewed and updated the clinical prior authorization criteria guides listed below. The Opioid Clinical Policy criteria is required for all Medicaid managed care organizations (MCOs). All other clinical prior authorizations are optional for MCOs. HHSC will notify pharmacies when we implement criteria for fee-for-service.

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. Pharmacies can use the MCO Search to find links to each MCO’s list of clinical prior authorizations.

ADD/ADHD Agents

ADD/ADHD Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to the Mood Stabilizers table
    • Caplyta (52616, 52617)
    • Quetiapine (93088) 
  • Updated ER Maximum dosing table with Xelstrym information

Allergen Extracts

Allergen Extracts clinical prior authorization criteria guide (PDF)

  • Added GCN to Auto-Injectable Epinephrine table
    • Auvi-Q (44487, 28038, 19862) 
  • Added GCN to Intranasal Corticosteroid table
    • RYALTRIS 665-25MCG SPRAY (49205)
    • Dymista (32099)
  • Added GCN to Intranasal Corticosteroid/Intranasal Antihistamine Combination Products table
    • Dymista and generic formulation, azelastine-fluticazone 137/50 mcg/SPR

Antiemetic Agents

Antiemetic Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to the the table for step #1, history of an antineoplastic agent
    • Balversa (46189, 46192, 46193)
    • Cotellic (40123)
    • Daurismo (45798, 45797)
    • Erleada (53749, 44446)
    • Gilotrif (34956, 34957, 34958)
    • Jaypirca (53627, 53626)
    • Koselugo (47908, 47909)
    • Krazati (53379)
    • Lenalidomide (26315, 27276, 31911, 34743, 27277, 26314)
    • Lorbrena (45988, 45687)
    • Lytgobi (52947)
    • Nilutamide (22645)
    • Orserdu (53629, 53628)
    • Scemblix (51417, 51418)
    • Sorafenib (26263)
    • Thalomid (95392, 98220, 19321, 28301)
    • Vanflyta (54518, 54517)
    • Vizimpro (40421, 40422, 40423)
    • Vonjo (51982)
    • Zykadia (46119)

Antimigraine Agents -Triptans

Antimigraine Agents -Triptans clinical prior authorization criteria guide (PDF)

  • Added additional check for contraindicated diagnoses for naratriptan and oral and sumatriptan
  • Nilutamide (22645)
  • Orserdu (53629, 53628)
  • Scemblix (51417, 51418)
  • Sorafenib (26263)
  • Thalomid (95392, 98220, 19321, 28301)
  • Vanflyta (54518, 54517)
  • Vizimpro (40421, 40422, 40423)
  • Vonjo (51982)
  • Zykadia (46119)

Antipsychotic Agents

Antipsychotic Agents clinical prior authorization criteria guide (PDF)

  • Added GCN to the Antipsychotics- First Generation drug table
    • Chlorpromazine vial (14421)
  • Added GCNs to the Drug Requiring Prior Authorization- Second Generation (Long-Acting Injectables)
    • Rykindo (20217, 20218, 20219)
    • Chlorpromazine vial (14421) 

Anxiolytics and Sedative-Hypnotics 

ASH clinical prior authorization criteria guide (PDF)

  • Updated Chlordiazepoxide/Mebrobamate/Oxazepam approval duration to 120 days on questions 1 and 11
  • Added GCN to Drugs Requiring Prior Authorization table
    • Ramelteon (25202)
  • Added GCNs to Drugs Requiring Prior Authorization table under Anxiolytics – Lorazepam
    • Loreev XR (50771, 52048, 50801, 50781)
  • Added age check for Loreev XR (18 and older)
    • Updated question 10 to show greater than or equal to 2 years of age (used to be greater than 2).

Buprenorphine Agents

Buprenorphine Agents clinical prior authorization criteria guide (PDF)

  • Updated approval duration to 180 days
  • Added new GCN to the supporting table
    • Morphine sulfate (32719)

Colchicine

Colchicine clinical prior authorization criteria guide (PDF)

  • Added GCNs to the Drugs Requiring Prior Authorization table
    • Colchicine (35674)
  • Added criteria for Lodoco as approved by the DUR Board

Cortisol Receptor Antagonists

paxpress.txpa.hidinc.com/recorlev.pdf

  • Renamed Recorlev to Cortisol Receptor Antagonists
  • Added Korlym (Mifepristone) to criteria 

COX2 Inhibitors

COX2 Inhibitors clinical prior authorization criteria guide (PDF)

  • Added GCNs to the table for step #11, history of DMARD agent for 30 days
    • Azathioprine (19170, 19173)
    • Enbrel (48417)
    • Penicillamine (07100, 07091) 

Cytokine and CAM Antagonists

Cytokine and CAM Antagonists clinical prior authorization criteria guide (PDF)

  • Added criteria for Litfulo as approved by the DUR Board
  • Added GCNs to the Drugs Requiring Prior Authorization tables for:
    • Adalimumab Biosimilars table
    • Biologic DMARD table
    • Conventional therapy for plaque psoriasis table
    • Simponi - contraindicated drugs table
      • Cyltezo (53842, 53841, 54205, 43789, 55665, 55668)
      • Hadlima (53848, 46718, 53846, 46717)
      • Adalimumab-fkjp and Hulio (48317, 48336, 48318)
      • Adalimumab-adaz (53875, 53884)
      • Adalimumab- Biosimilars (55665, 55668)
      • Adalimumab- ryvk (55332)
      • Hyrimoz (53887, 53899, 53875, 53884, 53883, 53885, 53878, 53891)
      • Simlandi (CF) (55332)
  • Added indication for hidradenitis suppurativa for Cosentyx
  • Updated age to 2 years and older for plaque psoriasis for Enbrel
  • Updated age to 2 years and older for psoriatic arthritis for Orencia 
  • Corrected Humira criteria logic for Crohn’s disease pathway to check for history of conventional therapy
  • Added criteria for Entyvio SC as approved by the DUR Board
    • Added table for conventional therapy for ulcerative colitis

Desmopressin

Desmopressin clinical prior authorization criteria guide (PDF)

  • Added GCNs to the table for history of an anti-hemophilic factors agent
    • AltuaSiiio (53758, 53759, 53755, 53764, 53765, 53756)
    • Coagadex (39952, 39954)
    • Esperoct (47508, 47509, 47514, 47515, 47507)
    • Ixinity (38648, 38655, 43172, 38646)
    • Jivi (45219, 45221, 45222, 45218)
    • Obizur (37321), Profilnine (25140, 25148, 25142)
    • Rixubis (34873, 34874, 34868, 34875, 34869)
    • Sevenfact (47889, 47891)

Diclofenac 3% Gel, Diclofenac 1.5% and 2% Topical Solution

Diclofenac 3% Gel, Diclofenac 1.5% and 2% Topical Solution clinical prior authorization criteria guide (PDF)

  • Added GCN to Drugs Requiring Prior Authorization table
    • Diclofenac 1% gel (45680)
  • Removed check for ingenol mebutate gel from question 4 in the diclofenac 3% criteria logic and diagram

DPP4 Inhibitors

DPP4 Inhibitors clinical prior authorization criteria guide (PDF)

  • Added GCN for saxagliptin to the Drugs Requiring Prior Authorization table for criteria set A
    • Saxagliptin (27393)
  • Added GCN for saxagliptin to the Drugs Requiring Prior Authorization table for criteria set C
    • Saxagliptin (27394)
  • Added GCN for saxagliptin to the Drugs Requiring Prior Authorization table for criteria set D
    • Saxagliptin-metformin (29118, 29225, 29224)

Dopamine Agonists (Apokyn and Kynmobi)

Dopamine Agonists clinical prior authorization criteria guide (PDF)

  • Added GCN to Drugs Requiring Prior Authorization table
    • Apomorphine (42078)

Enzymes

Enzymes clinical prior authorization criteria guide (PDF)

  • Added GCNs to Drugs Requiring Prior Authorization table for Nityr/Orfadin
    • Nitisinone (15664, 15662, 39031, 15663)  

Fentanyl Agents

Fentanyl Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to the table for history of antineoplastic agent
    • Balversa (46189, 46192, 46193)
    • Daurismo (45798, 45797)
    • Erleada (53749, 44446)
    • Gilotrif (34956, 34957, 34958)
    • Jaypirca (53627, 53626)
    • Koselugo (47908, 47909)
    • Krazati (53379)
    • lenalidomide (26315, 27276, 31911, 34743, 27277, 26314)
    • Lorbrena (45988, 45687)
    • Lytgobi (52947)
    • Nilutamide (22645)
    • Orserdu (53629, 53628)
    • Scemblix (51417, 51418)
    • Sorafenib (26263)
    • Vanflyta (54518, 54517)
    • Vizimpro (40421, 40422, 40423), Vonjo (51982), Xtandi (46626, 48452), and Zykadia (46119)
  • •    Added GCNs to the table for history of opioid therapy
  • o     Apadaz (45987, 44508, 45986)
  • o    Morphine sulfate (32719)

Forteo (Teriparatide)

Forteo (Teriparatide) clinical prior authorization criteria guide (PDF)

  • Added check for skeletal malignancies to step 2 of the logic and logic diagram
  • Added GCNs to the claim for other medication for osteoporosis table
    • Pamindronate (85997)
    • Risedronate (17378, 92238, 60511, 29223)

GI Motility Agents

GI Motility Agents clinical prior authorization criteria guide (PDF)

  • Added check for duplicate therapy for Amitza, Linzess, Lotronex, Motegrity, Relistor, and Trulance
  • Added GCNs to the Opioid table
    • Apadaz (45987, 44508, 45986)
    • Morphine sulfate (32719)
    • Dsuvia (45928)
  • Updated Trulance criteria logic question #3: if no, go to #4

GLP-1 Receptor Agonists

GLP-1 Receptor Agonists clinical prior authorization criteria guide (PDF)

  • Updated age for Trulicity to 10 years and older
    • Added check for ASCVD, HF and CKD without prior oral antidiabetic therapy for Ozempic, Trulicity and Victoza

HP Acthar

HP Acthar clinical prior authorization criteria guide (PDF)

  • Added GCN to Drugs Requiring Prior Authorization table
    • Cortropin gel (26016)

Ileal Bile Acid Transporter (IBAT) Inhibitors

Ileal Bile Acid Transporter (IBAT) Inhibitors clinical prior authorization criteria guide (PDF)

  • Added diagnosis of Alagille syndrome for Bylvay
    • Added a check for concurrent therapy with another IBAT inhibitor (already in the criteria for Livmarli)

Imiquimod

Imiquimod clinical prior authorization criteria guide (PDF)

  • Added ICD-10 codes for genital/perianal warts for imiquimod 3.75%

Ketorolac

Ketorolac clinical prior authorization criteria guide (PDF)

  • Added GCNs to table 4, History of warfarin, heparin, low-molecular weight heparin (LMWH) or other antihemophilic drug.
    • Adynovate (40207, 40208, 40209, 40213, 43009, 43013, 43353)
    • Afstyla (41497, 41499, 41501, 41502, 41503)
    • Alprolix (36333, 36334, 36335, 36336, 40816, 42556)
    • Altuviiio (53755, 53756, 53758, 53759, 53764, 53765),
    • Coagadex (39952, 39954)
    • Corifact kit (29584)
    • Eloctate (36657, 36658, 36662, 36663, 36664, 36665, 36666, 43115, 43116, 43114)
    • Esperoct (47508, 47509, 47514, 47515, 47507)
    • Idelvion (40749, 40751, 40752, 40753, 44859)
    • Ixinity (38646, 38648, 38655, 43172)
    • Jivi (45218, 45219, 45221, 45222)
    • Kovaltry (98833, 38831, 98832, 98764, 98634)
    • Novoeight (37395, 37396, 37397, 37393, 37398, 37397)
    • Nuwiq (38023, 38024, 38025, 38027, 43791, 43792, 43793)
    • Obizur (37321), Rixubis (34868, 34869, 34873, 34874, 34875)
    • Sevenfact (47889, 47891), and Wilate ( 32238, 32239)

Leukotriene Modifiers

Leukotriene Modifiers clinical prior authorization criteria guide (PDF)

  • Added GCNs for steps checking for prior claims for ICS, ICS/LABA, INC, or SABA. And for steps checking for prior claims for ICS or LABA/ICS combination
    • AirDuo Digihaler 113-14 mg, 232-14mg, and 55-14 mcg (48495, 48494, and 48489)
    • Fluticasone HFA 110 mcg, 220 mcg, and 44 mcg (53636, 53639, and 53638)
    • Fluticasone-vilanterol 100-25 mcg and 220-25 mcg (34647 and 35808)
    • Breyna 160-4.5 mcg (98500), 80-4.5 mcg (98499)
    • Wixela 100-50 Inhub (50584), 250-50 Inhub (50594), 500-50 Inhub (50604)
    • Azelastine-fluticasone SPR 137-50mcg (32099)
    • Omnaris 50mcg nasal Spray (97453)
    • Ryaltris 665-25mcg SPR (49205)
    • Stiolto Respimat INH SPR (38687)

Lyrica

Lyrica clinical prior authorization criteria guide (PDF)

  • Removed age check for Lyrica IR

Monoclonal Antibody Agents

Monoclonal Antibody Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to the Asthma Controller Medication
    • AirDuo Digihaler 113-14 mcg, 232-14 mcg, and 55-14 mcg (48494, 48495, and 48489)
    • Armonair Respiclick 232 mcg and 55 mcg (42985 and 42979)
    • Armonair Digihaler 55 mcg, and 113 mcg, and 232 mcg (48602, 48604, and 48615) 
    • Asmanex HFA 50 mcg, 100 mcg, and 200 mg (47599, 37566, 37565)
    • Breyna 160-4.5 mcg and 80-4.5 mcg (98500 and 98499)
    • Budesonide-formoterol 160-4.5 mcg and 80-4.5 mcg, (98500 and 98499)
    • Fluticasone prop diskus 100 mcg, 250 mcg, and 50 mcg (53633, 53634, and 53635)
    • Fluticasone propionate HFA 110 mcg, 220 mcg, and 44 mcg (53636, 53639, and 53638)
    • Fluticasone-vilanterol 100-25 mcg and 200-25 mcg (34647 and 35808) 
  • Added GCN to Intranasal Corticosteroid (INS) table
    • Ryaltris 665-25 mcg spray (49205) 
  • Updated age indication for Adbry to 12 years and older
  • Updated the followings for Dupixent criteria 
    • Age indication for eosinophilic esophagitis to 1 year and older with weight greater than or equal to 15 kg.
    • Criteria flow for step 4 (Is the client greater than or equal to 6 years of age?); from ‘No (Deny) to ‘No (Go to #7)
    • Included diagnosis of IgG-mediated food allergy for clients 1 year or older for Xolair.
  • Expanded age indication for Fasenra for indication of add-on maintenance treatment of patients aged 6 years and older with severe asthma, and with an eosinophilic phenotype

Multiple Sclerosis

Multiple Sclerosis clinical prior authorization criteria guide (PDF)

  • Added criteria for Tascenso ODT as approved by the DUR Board, including a step for renewal requests
    • Added GCNs for teriflunomide (33259, 33262) to drug table

Omega-3 Fatty Acids

Omega-3 Fatty Acids clinical prior authorization criteria guide (PDF)

  • Updated maximum dosing to ≤ 4 grams per day
  • Added GCN to fibrate table
    • Fenofibrate (35563)

Opiate/Benzodiazepine/Muscle Relaxant Combinations

Opiate/Benzodiazepine/Muscle Relaxant Combinations clinical prior authorization criteria guide (PDF)

  • Updated HIC3 column in the Drugs Requiring Prior Authorization Table:
    • Oxycodone-apap (GCN 70470) to H3U
    • Tramadol 100mg (GCN 92069) to H3A
    • Alprazolam, chlordiazepoxide, clorazepate, diazepam, lorazepam (oral), and oxazepam GCNs to H2O 
    • Clonazepam GCNs to H4A
    • Estazolam, flurazepam, lorazepam (injectable), temazepam, and triazolam GCNs to H21
  • Added GCNs to Drugs Requiring Prior Authorization table 
    • Loreev XR (50771, 52048, 50801, 50781)
    • Morphine sulfate (32719
  • Added GCN to Drugs requiring prior authorization
    • Morphine sulfate (32719)

Opiate Overutilization

Opiate Overutilization clinical prior authorization criteria guide (PDF)

  • Added GCNs to Opiate Analgesics table
    • Fentanyl buccal tabs (97280, 97281, 97283, 97284, 97285
    • Meperidine (15991)
    • Morphine sulfate (32719)
    • Oxymorphone (99494)

Opioid Policy Criteria

Opioid Policy Criteria clinical prior authorization criteria guide (PDF)

  • Added GCN to Drug Requiring Review
    • Morphine sulfate (32719)

Oxycodone Extended Release Agents

Oxycodone Extended Release Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to History of an antineoplastic agent table
    • Abiraterone (29886, 43205)
    • Afinitor (20784, 20844, 28783, 31396, 34589, 34590, 34592)
    • Alcensa (40299)
    • Alunbrig (43326, 43325, 44305, 44306)
    • Ayvakit (47516, 47517, 49825, 47518, 49826)
    • Balversa (46189, 46192, 46193)
    • Braftovi (44924, 44925)
    • Brukinsa (47336)
    • Cabometyx (41146, 41147, 41148)
    • Calquence (44011, 52674)
    • Copiktra (45424, 45425)
    • Cotellic (40123)
    • Daurismo (45798, 45797)
    • Erleada (53749, 44446)
    • Everolimus (28783, 20784, 20844, 31396, 34589, 34590, 34592)
    • Exkivity (50987)
    • Fotivda (46162, 46287)
    • Gavreto (48566)
    • Gilotrif (34956, 34957, 34958)
    • Idhifa (43689, 43688)
    • Imatinib (19908, 19907)
    • Inqovi (48323)
    • Inrebic (46818)
    • Kisqali (43162, 43166, 43167)
    • Koselugo (47908, 47909)
    • Lapatinib (98140)
    • Lenalidomide (31911, 26314, 26315, 27277, 27276, 34743)
    • Lonsurf (39597, 39596)
    • Lorbrena (45688, 45987)
    • Lumakras (49716, 53809)
    • Lynparza (37611, 43766, 43765)
    • Lytgobi (52947)
    • Mektovi (44926)
    • Melphalan (38380)
    • Nerlynx (43613)
    • Nilutamide (43613)
    • Ninlaro (40189, 40193, 40194)
    • Nubeqa (46746)
    • Odomzo (39217)
    • Onureg (48545, 48540)
    • Orgovyx (49005)
    • Pemazyre (47935, 47933, 47934)
    • Piqray (46362, 46358, 46359)
    • Pomalyst (34147, 34148, 34149, 34150)
    • Qinlock (48075)
    • Retevmo (48025, 48026)
    • Revlimid (31911, 26314, 26315, 27276, 34743, 27277)
    • Rozlytrek (46815, 46816)
    • Rubraca (42795, 43453, 42796)
    • Rydapt (43327)
    • Scemblix (51417, 51418)
    • Sorafenib (26263)
    • Sunitinib (26452, 26453, 35596, 266454)
    • Tafinlar (34724, 34723, 53863)
    • Tabrecta (48012, 48013)
    • Tagrisso (40132, 40133)
    • Talzenna (45595, 45596)
    • Tazverik (47169)
    • Tepmetko (49154)
    • Thalomid (28301, 95392, 98220, 19321)
    • Tibsovo (46016)
    • Truseltiq (49714, 49715, 49708, 49713)
    • Tukysa (47931, 47929)
    • Turalio (53437, 46762)
    • Venclexta (41049, 41051, 41052, 41048)
    • Verzenio (43918, 43917, 43916, 43915)
    • Vitrakvi (45793, 45794, 45789)
    • Vizimpro (40421, 40422, 40423)
    • Vonjo (51982)
    • Welireg (50046)
    • Xospata (45803)
    • Xpovio (46637, 46636, 48266, 46634, 46635, 48271, 48265, 49538, 49533, 49534, 49539, 49537)
    • Yonsa (44795)
    • Zejula (44795, 54055, 54056, 54057, 43217)
  • Added GCNs to the table for step#4, <14 days of opioid therapy
    • Buprenorphine patch (25309, 35214, 25312,25308, 36946)

Pulmonary Hypertension Agents

Pulmonary Hypertension Agents clinical prior authorization criteria guide (PDF)

  • Added GCNs to Oral PHA Drugs Requiring Prior Authorization table
    • Opsynvi (51671, 55446) to oral agents
  • Added GCNs to Injectable PHA Drugs Requiring Prior Authorization table
    • Added GCNs for Winrevair (55485, 55487) to injectable agents

Vesicular Monoamine Transporter 2 Inhibitors

VMAT2 Inhibitors clinical prior authorization criteria guide (PDF)

  • Added GCNs to the Drugs Requiring Prior Authorization
    • Ingrezza (55669, 55672, 55673)
  • Removed check for dopamine blocking agents
  • Added a check for strong CYP2D6 inhibitors for Ingrezza