Clinical Prior Authorizations for Managed Care

Managed care organizations have the option to use any of the below clinical prior authorizations approved by the Texas Drug Utilization Review Board.

The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. Pharmacies providers should contact the client's specific MCO for details.

Refer to the clinical prior authorizations implemented in traditional Medicaid.

Required

Clinical prior authorizations required by MCOs to perform for clients enrolled in Medicaid include the following:

  1. Hormonal Therapy Agents (PDF) (beginning March 1, 2024)
  2. Promethazine Agents (PDF)
  3. Synagis (PDF)

Refer to the "Required MCO Clinical Prior Authorizations" section of the Pharmacy Provider Procedures Manual for more information.

Optional

The following clinical prior authorizations are those MCOs have the option to perform for clients enrolled in Medicaid or CHIP.

  1. ADD/ADHD Medications (PDF)
  2. Aliskiren-Containing Agents (except Valturna) (PDF
  3. Allergen Extracts - Oralair (PDF)
  4. Altabax (retapamulin) (PDF)
  5. Amantadine ER (PDF)
  6. Amyotrophic Lateral Sclerosis (ALS) Agents (PDF)
  7. Androgenic Agents (PDF)
  8. Antiemetics (PDF)
  9. Antifungal Agents, Topical (PDF)
  10. Antimigraine Agents, Triptans (PDF)
  11. Antipsychotics (PDF)
  12. Antiseizure Agents, Epidiolex and Fintepla (PDF)
  13. Antimigraine Agents, Ergot Derivatives (PDF)
  14. Anxiolytics and Sedatives/Hypnotics (PDF)
  15. Appetite Suppressant Agents (PDF)
  16. Arikayce (PDF)
  17. Binge Eating Disorder (BED) Agents (PDF)
  18. Buprenorphine Agents (PDF)
  19. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute (PDF)
  20. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis (PDF)
  21. Carisoprodol Containing Agents (PDF)
  22. Carisoprodol Overuse (PDF)
  23. Central Nervous System Stimulants (PDF)
  24. Colchicine Agents (PDF)
  25. Cough and Cold Medications (PDF)
  26. COX-2 Inhibitors (PDF)
  27. Cyclobenzaprine (PDF)
  28. Cymbalta (duloxetine) (PDF)
  29. Cystic Fibrosis Agents (PDF)
  30. Cytokine and CAM Antagonists (PDF)
  31. Daybue (trofinetide)
  32. Desmopressin (PDF)
  33. Dextromethorphan Overutilization (PDF)
  34. Diabetic Test Strips (PDF)
  35. Diclofenac (PDF)
  36. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  37. Dopamine Agonists (PDF)
  38. Doxylamine/Pyridoxine (PDF)
  39. Duplicate Therapy (PDF)
  40. Emflaza (PDF)
  41. Enzymes (PDF)
  42. Erythropoiesis-Stimulating Agents (PDF)
  43. Evrysdi (PDF)
  44. Fecal Microbiota Transplantation (FMT) (PDF) 
  45. Fentanyl Agents (PDF)
  46. Filspari (Sparsentan)(PDF)
  47. Forteo (teriparatide) (PDF)
  48. Gabapentin Agents (PDF)
  49. Gattex (teduglutide) (PDF)
  50. Gaucher's Disease Agents (PDF)
  51. GI Motility Agents (PDF)
  52. Glatiramer Acetate Injection (PDF)
  53. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  54. Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (PDF)
  55. Growth Hormones (PDF)
  56. H.P. Acthar (PDF)
  57. Hemady (PDF)
  58. Hereditary Angioedema (PDF)
  59. Hyperlipidemia Agents (PDF)
  60. Ileal Bile Acid Transporter (IBAT) Inhibitors (PDF)
  61. Imcivree (Setmelanotide) (PDF)
  62. Imiquimod (PDF)
  63. Immunomodulator Agents for Dry Eye (PDF)
  64. Increlex (mecasermin) (PDF)
  65. Inhaled Antibiotics (PDF)
  66. Ketorolac (Toradol) (PDF)
  67. Keveyis (PDF)
  68. Leukotriene Modifiers (PDF)
  69. Lidocaine Patches (PDF)
  70. Lupus Agents (PDF)
  71. Lyrica (pregabalin) (PDF)
  72. Monoclonal Antibody Agents (PDF)
  73. Multiple Sclerosis Agents (PDF)
  74. Nitazoxanide (PDF)
  75. Nuedexta (dextromethorphan/quinidine) (PDF)
  76. Nuplazid (PDF)
  77. Omega-3 Fatty Acids (PDF)
  78. Opiate Overutilization (PDF)
  79. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  80. Orilissa (PDF)
  81. Oxervate (PDF)
  82. Oxycodone Extended-Release Products (PDF)
  83. Palforzia (PDF)
  84. Phosphodiesterase 5 (PDE5) Inhibitors (PDF)
  85. Phosphate Binders (PDF)
  86. Plavix (clopidogrel) (PDF)
  87. Propylthiouracil (PDF)
  88. Proton Pump Inhibitors (PDF)
  89. Pulmonary Arterial Hypertension (PDF)
  90. Pulmozyme (PDF)
  91. Ranexa (PDF)
  92. Recorlev (levoketoconazole) (PDF)
  93. Recurrent Vulvovaginal Candidiasis (RVVC) Agents (PDF)
  94. Rezurock (Belumosudil) (PDF)
  95. Savella (milnacipran) (PDF)
  96. Sickle Cell Agents (PDF)
  97. Skyclarys (Omaveloxolone) (PDF)
  98. Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (PDF)
  99. Sphingosine 1-Phosphate (S1P) Receptor Modulators (PDF)
  100. Symlin (pramlintide Acetate) (PDF)
  101. Thiazolidinediones (PDF)
  102. Topical Acne Agents (PDF)
  103. Topical Immunomodulators (PDF)
  104. Topical Retinoids (PDF)
  105. Transthyretin Agents (PDF)
  106. Urea Cycle Disorder Agents (PDF)
  107. Veozah (fezolinetant) (PDF) 
  108. Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
  109. Voxzogo (vosorititde) (PDF)
  110. Xifaxan (rifaximin) (PDF)
  111. Xyrem/Xyway PDF)
  112. Zelboraf (vemurafenib) (PDF)
  113. Ztalmy (PDF)