Medicaid Clinical Prior Authorization

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.

Optional Managed Care Clinical Prior Authorization

Implementation of all other board-approved clinical prior authorization is optional and will vary between HHSC 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 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.

Required Managed Care Clinical Prior Authorization

HHSC requires MCOs to implement specific clinical prior authorizations for clients enrolled in managed care. The information below identifies the dates MCOs implemented 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