13. Prior Authorization

13.2. CSHCN Services Program

The CSHCN Services Program requires prior authorization for the following drugs:

  • Cystic Fibrosis products (includes Cayston, Kalydeco, Pulmozyme, and Tobi)
  • Growth Hormone products
  • Synagis

Refer to the CSHCN Services Program Prior Authorization Requests section for a list of request and addendum forms.

Prescribing providers must send a letter of medical necessity on office stationery to the CSHCN Service Program for the following drugs:

  • Family planning products
  • Human Immunodeficiency Virus (HIV) drugs
  • Pulmonary hypertension drugs

Refer to the CSHCN Services Program - Prior Authorization Contacts section for program contact information.

The program may cover HIV drugs when prior authorized for the treatment of HIV/AIDS, while the person completes the Texas HIV Medication Program eligibility process. Covered HIV medications are subject to change. People have up to 60 days of prior approval while waiting for acceptance or denial from the Texas HIV Program.

After the 60 days prior approval period, the person must contact the Texas HIV Program to obtain these medications. Claims for these drugs will reject with NCPDP code 75 ("Prior Authorization Required") and include the message “Call HIV Program 1-800-255-1090” in the “Additional Message Information” field (526FQ), except when the person is not eligible for the drug from the HIV Program. In these cases, the CSHCN Services Program should be notified and the claim will process for payment under CSHCN.

3.1 Texas Standard Prior Authorization Form

Prescribing providers may also submit prior authorization requests using the Texas Standard Prior Authorization Form.

3.2 Appeal Information

Either the person or the prescribing provider may appeal a denial for authorization or payment. Routine adjustments to claims are handled through the HHS Pharmacy Benefits Access Help Desk. Other appeals, administrative reviews, and due process hearing requests for services authorized and paid by CSHCN must be submitted in writing. Refer to the “Children with Special Health Care Needs Services Program” section of the Contacts chapter of the PPPM for program mailing address.

Failure to submit an appeal, administrative review, or due process hearing request in writing to the program within the deadlines defined below is considered a waiver of the right to appeal, to administrative review, or to due process hearing.

Claims that are denied must be resubmitted for appeal within 180 days from the date of the initial denial. Claims that are denied on written appeal must be submitted for administrative review within 30 days of the date on the appeal denial letter. A due process hearing must be requested within 20 days of the date on the administrative review denial letter.

Authorizations that are denied must be submitted for appeal or administrative review within 30 days of the date when authorization of services was denied. All appeal materials, including medical reports, forms, and a medical/financial rationale for appeal must be submitted within the deadline. A due process hearing must be requested within 20 days of the date on the letter denying administrative review.

3. Texas Standard Prior Authorization Forms

The Texas Department of Insurance requires Medicaid to publish the Texas Standardized Prior Authorization Request Form for Health Care Services (TDI Form NOFR002) for prescribing providers as of September 1, 2015.  Refer to 1 TAC Section 19.1820 (Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use) on the VDP website Rules and Statutes page (txvendordrug.com/about/rules). 

Providers use this form to request prior authorization by fax or mail.  Some medications will require providers to submit an addendum form to capture additional information.  Failure to submit both the Standardized Prior Authorization Request and addendum may result in an authorization denial.

Refer to the Medicaid Fee-for-service Prior Authorization Requests section for a list of addendum forms.

Refer to the CSHCN Services Program Prior Authorization Requests section for a list of addendum forms.

P-13.1. Medicaid

Prior authorization is a process used to determine if a prescribed procedure, service, or medication is necessary, appropriate, and not likely to cause adverse effects. Prescribing providers must submit an authorization request for the drug before Medicaid pays the claim.

Each MCO administers pharmacy prior authorization services for clients enrolled in managed care. The Texas Prior Authorization Call Center manages prior authorizations for clients in Medicaid fee-for-service.

All clients enrolled in Medicaid adhere to the same formulary. Some drugs on the formulary may require prior authorization. There are two types of prior authorizations impacting a covered Medicaid outpatient drug on the formulary

  • Clinical
  • Non-preferred

Some drugs or drug classes are subject to both non-preferred and clinical prior authorizations.

The Texas Drug Utilization Review (DUR) Board reviews classes of drugs every quarter and recommends drugs for preferred or non-preferred status on the Texas Medicaid Preferred Drug List (PDL), and establishes recommendations for clinical prior authorizations.

13.1.4. Emergency Override

The pharmacy should provide a 72-hour emergency supply of the prescribed drug when a client needs medication without delay and prior authorization is not available. This applies to drugs that are non-preferred on the preferred drug list and or drugs subject to clinical prior authorization. The emergency override protocol applies to clients enrolled in both traditional Medicaid or Medicaid managed care.

Before dispensing a 72-hour emergency supply, the dispensing pharmacist should use professional judgment to determine if taking the prescribed medication jeopardizes the client's health or safety and make good faith efforts to contact the prescribing provider.

A 72-hour emergency prescription will be paid in full, and it does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month. This procedure should not be used for routine and continuous overrides.

Pharmacy staff should submit the information in the table below for emergency override claims.

Field Name Field Number Value

Prior Authorization Type Code

461-EU

8

Prior Authorization Number Submitted

462-EV

8Ø1

Days Supply 4Ø5-D5 3
Quantity Dispensed 442-E7 The submitted amount should not exceed the quantity necessary for a three-day supply according to the directions for administration given by the prescriber. If the medication is a dosage form that prevents a three-day supply from being dispensed (e.g., an inhaler), it is still permissible to indicate that the emergency prescription is a three-day supply, and enter the full quantity dispensed.

Download the Dispensing 72-hour Emergency Prescriptions Instructions to distribute to staff and display in your pharmacy.

P-13.1.1. Clinical

Clinical prior authorizations may apply to a particular drug or an entire drug class on the formulary, including preferred and non-preferred drugs.

HHSC establishes clinical prior authorizations based on recommendations from the DUR board using the latest FDA-approved product labeling, national guidelines, peer-reviewed literature, and evidence-based clinical criteria. The board reviews prospective clinical prior authorizations criteria proposed by HHSC in collaboration with MCOs and other stakeholders.

HHSC and MCOs may implement board-recommended clinical prior authorizations at any time. HHSC requires MCOs to perform specific clinical prior authorizations. The usage of the other clinical prior authorizations will vary between each MCO.

Each clinical prior authorization has a criteria guide describing how Medicaid evaluates requests. All steps in the criteria guide apply to traditional Medicaid claims. MCOs may decide to use any or all of the approved criteria as long as the prior authorization is not more restrictive.

Refer to the clinical prior authorization criteria guides at the Texas Prior Authorization Portal (paxpress.txpa.hidinc.com) for more information.

Refer to the Pharmacy Clinical Prior Authorization Assistance Chart for a list of the clinical prior authorizations each MCO uses and how those authorizations relate to those used for processing fee-for-service Medicaid claims.

Clinical prior authorizations are periodically revised to ensure they reflect prescribing recommendations of the current state and nationally established drug criteria, information from approved compendia, and the peer-reviewed literature.

P-13.1.1.1. Required MCO Clinical Prior Authorizations

HHSC requires MCOs to implement specific clinical prior authorizations for clients enrolled in managed care. The table below identifies the dates MCOs must implement specific clinical prior authorizations. Clinical prior authorizations with an end date are no longer required and are now optional. Refer to the Pharmacy Clinical Prior Authorization Assistance Chart to identify whether an MCO still uses the criteria.

Clinical Prior Authorization Required Start Date Required End Date
Antipsychotics March 1, 2012 May 15, 2018
Hepatitis C Virus April 8, 2015  
Orkambi (part of Cystic Fibrosis Agents) January 21, 2016 March 1, 2021
Promethazine/Promethazine Containing Products March 1, 2012  
Synagis September 23, 2014  

P-13.1.1.2. Optional MCO Clinical Prior Authorizations

Implementation of all other board-approved clinical prior authorization is optional and will vary between VDP and the MCOs at the discretion of each MCO. An MCO may use any or all of the board-recommended clinical prior authorizations criteria but is not permitted to implement more stringent prior authorization criteria than the board approved.

Refer to the VDP website Managed Care Clinical Prior Authorization page (txvendordrug.com/formulary/prior-authorization/mco-clinical-pa) for the list of clinical prior authorizations MCOs have the option to perform for people enrolled in Medicaid.

Refer to the VDP website MCO Resources page (txvendordrug.com/resources/managed-care/mco-resources) for a link to the clinical prior authorization page on each MCO's website.

P-13.1.1.3. Fee-for-service Clinical Prior Authorizations

Refer to the VDP website Fee-for-service Clinical Prior Authorization page (txvendordrug.com/formulary/prior-authorization/ffs-clinical-pa) for the list of clinical prior authorizations HHSC implemented for people enrolled in traditional Medicaid.

HHSC pharmacists review prior authorization requests for the following drugs:

  • Xenical (orlistat)

Refer to the list of Medicaid FFS Prior Authorization Requests for forms. Refer to the instructions on each form for submission information.

P-13.1.2. Non-preferred

HHSC arranges the PDL by drug class, and it contains a subset of many, but not all, drugs found on the Medicaid formulary. Preferred drugs on the PDL are selected using criteria based on safety, efficacy and cost, and are available without prior authorization unless there is a clinical prior authorization associated with the drug. Non-preferred drugs require a PDL prior authorization. Some preferred drugs may also require clinical prior authorization.

The PDL Criteria Guide explains the criteria used to evaluate the non-preferred prior authorization requests.

MCOs use the same non-preferred prior authorization criteria requirements but may have non-preferred requirements on a limited set of home health supplies provided by Medicaid-enrolled pharmacies.

P-13.1.2.1. Preferred Drug List

The DUR board makes PDL recommendations each quarter and submits them for review to the HHSC Executive Commissioner.  The biannual PDL incorporates the commissioner’s decisions on the schedule identified in the following table.

Board Meets / PDL Recommendations Published PDL Published
January July
April July
July January
October January

Refer to the VDP website DUR Board Agenda and Documents page (txvendordrug.com/resources/drug-utilization-review-board/meeting-agendas-and-documents) for each board meeting's recommendations and the HHS-approved decisions.

HHSC organizes the PDL by therapeutic class, identifying the preferred agents, non-preferred agents, and any prior authorization criteria. The PDL identifies drugs requiring clinical prior authorization with a hyperlink to the clinical criteria document.

Refer to the VDP website Preferred Drug page (txvendordrug.com/formulary/prior-authorization/preferred-drugs) to review the latest edition of the PDL.

The VDP Formulary Drug Search identifies drugs requiring non-preferred prior authorization. Users can select the "PDL PA Required" check-box for the list of drugs.

P-13.1.3. Obtaining Prior Authorization

In certain instances, pharmacy and medical claims data will be available to indicate when a person has met the prior authorization criteria. In those cases, the prescription is authorized automatically at the point of sale without any notification to prescribing provider or dispensing pharmacy.

If supporting claims data is not available to the automated prior authorization system, the claim will reject with NCPDP error code 75 ("Prior Authorization Required").  Pharmacy staff should notify the prescribing providers or their representatives about the prior authorization requirement so they can request authorization.  Pharmacy staff cannot request authorization.  A decision from the prior authorization authority to approve or deny the request is made within 24 hours of the initial request.

Refer to the contact section for FFS Medicaid Clinical Prior Authorization contact information.

Refer to the contact section for FFS Medicaid Non-preferred Prior Authorization contact information.

Refer to the contact section for MCO Prior Authorization contact information.

P-13.1.5. Reconsideration

The prescribing provider may request reconsideration if the prior authorization request is denied.

Prescribing providers should contact the Texas Prior Authorization Call Center for the fee-for-service Medicaid prior authorization reconsideration process. Refer to the Medicaid FFS Prior Authorization Requests for the Texas Medicaid Prior Authorization Reconsideration Request (HHS Form 1322).

Prescribing providers should contact the MCO for its reconsideration process for clients enrolled in managed care.