Medicaid Non-preferred Prior Authorization
HHSC organizes the preferred drug list (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.
The PDL document is separated 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.
The PDL Criteria Guide explains the criteria used to evaluate the non-preferred prior authorization requests.
The Formulary search (txvendordrug.com/formulary/formulary-search) identifies drugs requiring non-preferred prior authorization. Users can click the " PDL PA Required" dropdown and select “yes” for all drugs requiring prior authorization or “no” for all drugs not requiring prior authorization.
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.
Refer to the Preferred Drug List Process to learn how HHSC includes drugs on the PDL. Refer to the Preferred Drug Documents for quarterly PDL recommendations and biannual PDL documents and criteria guide.
Preferred Drug List Process
Refer to the Medicaid Non-preferred Prior Authorization section for more information. Refer to the Preferred Drug Documents for quarterly PDL recommendations and biannual PDL documents and criteria guides.
Tentative Yearly Drug Class Review Schedule Published
At the end of each calendar year, HHSC publishes a tentative schedule of the drug classes planned for review at the following year’s Texas Drug Utilization Review Board meetings. HHSC establishes the schedule and accounts for various seasonal health conditions, such as influenza.
Tentative Quarterly Drug Class Review Schedule Published
After each DUR Board meeting, HHSC publishes a tentative list of drug classes for review at the next board meeting.
DUR Board Agenda Published
A month before the meeting, HHSC finalizes the DUR board agenda with the drugs and drug classes scheduled for review.
Presentation to DUR Board
Contractor staff present information to the board on behalf of HHSC about existing drug classes and therapeutic and clinical drug information regarding new drugs up for the current quarter review. The public can testify in front of the board about these drugs.
Refer to the Testimony information in the Texas Drug Utilization Review Board Handbook for testimony forms and instructions.
Refer to Live and Archived Meetings page on the HHSC website (hhs.texas.gov/about/live-archived-meetings) for webcasts of past DUR board meetings.
PDL Recommendations Published
The board recommends drugs and drug classes for inclusion to the PDL based on clinical, financial, and safety at each board meeting. HHSC publishes a list of the recommendations online within 10 business days after each meeting.
PDL Decisions Published
The Texas HHSC Executive Commissioner reviews and approves the list of recommended PDL changes. HHSC publishes the list of the approved decisions 2-3 months after each meeting.
PDL and Criteria Guide Published
HHSC publishes the PDL document twice a year based on the following schedule:
- The Jan. PDL includes recommendations from the July and Oct. board meetings
- The July PDL includes recommendations from the Jan. and April board meetings
The Preferred Drug List Criteria Guide outlines the criteria used to evaluate the non-preferred prior authorization requests. HHSC updates the criteria at the same time as the PDL.
Schedule
The following table identifies the PDL events and when they occur.
| Board Meets | PDL Recommendations Published | PDL Decisions Published | PDL Published |
|---|---|---|---|
| Jan. | Jan. | March-April | July |
| April | April | June-July | July |
| July | July | Sept.-Oct. | Jan. |
| Oct. | Oct. | Dec.-Jan. | Jan. |