Clinical Prior Authorizations for Traditional Medicaid

The following clinical prior authorizations apply to people enrolled in traditional Medicaid. Refer to the clinical prior authorizations approved for use in Medicaid managed care.

Prescribing providers or their representatives should contact the Texas Pharmacy Prior Authorization Call Center to submit a prior authorization request.

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.

  1. ADD/ADHD Agents (PDF)
  2. Aliskiren-Containing Agents (except Valturna) (PDF)
  3. Allergen Extracts - Oralair (PDF)
  4. Altabax (retapamulin) (PDF)
  5. Antiemetic Agents (PDF)
  6. Antimigraine Agents, Ergot Derivatives (PDF)
  7. Antimigraine Agents, Triptans (PDF)
  8. Antipsychotics Agents (PDF)
  9. Anxiolytics and Sedatives/Hypnotics (PDF)
  10. Buprenorphine Agents (PDF)
  11. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute (PDF)
  12. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis (PDF)
  13. Carisoprodol (PDF)
  14. Central Nervous System (CNS) Stimulants (PDF)
  15. Corticotrophin (Formerly HP Acthar) (PDF)
  16. Cough/Cold Medications (PDF)
  17. COX-2 Inhibitors (PDF)
  18. Cyclobenzaprine (PDF)
  19. Cystic Fibrosis Agents (PDF)
  20. Cytokine and CAM Antagonists (PDF)
  21. Daybue (trofinetide) (PDF)
  22. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  23. Desmopressin (PDF)
  24. Dextromethorphan Overutilization (PDF)
  25. Dupixent (PDF)
  26. Duplicate Therapy (PDF)
  27. Emflaza (PDF)
  28. Enzymes (PDF)
  29. Erythropoiesis-Stimulating Agents (PDF)
  30. Fentanyl Agents (PDF)
  31. Gattex (PDF)
  32. Gaucher's Disease Agents (PDF)
  33. GI Motility Agents (PDF)
  34. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  35. Growth Hormone Agents (PDF)
  36. Hereditary Angioedema (HAE) Agents (PDF)
  37. Hormonal Therapy Agents (PDF) (beginning March 1, 2024)
  38. Hyperlipidemia Agents (PDF)
  39. Imiquimod (PDF)
  40. Increlex (mecasermin) (PDF)
  41. Inhaled Antibiotics (PDF)
  42. Ketorolac (Toradol) (PDF)
  43. Leukotriene Modifiers (PDF)
  44. Monoclonal Antibodies (Fasenra and Nucala) (PDF)
  45. Nitazoxanide (PDF)
  46. Nuedexta (dextromethorphan/quinidine) (PDF)
  47. Neurontin (gabapentin) (PDF)
  48. Omega-3 Fatty Acids (PDF)
  49. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  50. Opiate Overutilization (PDF)
  51. Oxycodone Extended-Release Agents (PDF)
  52. PDE5-Inhibitors (PDF)
  53. Phosphate Binders (PDF)
  54. Promethazine/Promethazine Containing Products (PDF)
  55. Propylthiouracil (PDF)
  56. Pulmonary Hypertension Agents (PDF)
  57. Ranexa (PDF)
  58. Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (PDF)
  59. Symlin (pramlintide Acetate) (PDF)
  60. Synagis (palivizumab) (PDF)
  61. Thiazolidinediones (PDF)
  62. Topical Immunomodulators (PDF)
  63. Vesicular Monoamine Transports 2 (VMAT2) Inhibitors (PDF)
  64. Wegovy (PDF)
  65. Xifaxan (rifaximin) (PDF)
  66. Xyrem (PDF)
  67. Zelboraf (vemurafenib) (PDF)
  68. Zepbound (PDF)