Clinical Prior Authorization - Traditional Medicaid

Refer to the clinical prior authorizations approved for use in Medicaid managed care.

The following clinical prior authorizations apply to people enrolled in traditional Medicaid.

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 Medications (PDF)
  2. Aliskiren-Containing Agents (except Valturna) (PDF)
  3. Allergen Extracts - Oralair (PDF)
  4. Altabax (retapamulin) (PDF)
  5. Antiemetics (PDF)
  6. Antipsychotics (PDF)
  7. Anxiolytics and Sedatives/Hypnotics (PDF)
  8. Buprenorphine Agents (PDF)
  9. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis (PDF)
  10. Carisoprodol (PDF)
  11. Central Nervous System Stimulants (PDF)
  12. Cough/Cold Medications (PDF)
  13. COX-2 Inhibitors (PDF)
  14. Cystic Fibrosis Agents (PDF)
  15. Cytokine and CAM Antagonists (PDF)
  16. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  17. Desmopressin (PDF)
  18. Dextromethorphan Overutilization (PDF)
  19. Dupixent (PDF)
  20. Duplicate Therapy (PDF)
  21. Emflaza (PDF)
  22. Enzymes (PDF)
  23. Erythropoiesis-Stimulating Agents (PDF)
  24. Fentanyl Agents (PDF)
  25. Flexeril/Amrix (cyclobenzaprine) (PDF)
  26. GI Motility Agents (PDF)
  27. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  28. Growth Hormones (PDF)
  29. Hepatitis C Virus (PDF)
  30. H.P. Acthar (PDF)
  31. Hyperlipidemia Agents (PDF)
  32. Imiquimod (PDF)
  33. Increlex (mecasermin) (PDF)
  34. Ketorolac (Toradol) (PDF)
  35. Leukotriene Modifiers (PDF)
  36. Lovaza (omega-3-acid ethyl esters) (PDF)
  37. Makena (PDF)
  38. Monoclonal Antibody Agents for Asthma (PDF)
  39. Nitazoxanide (PDF)
  40. Nuedexta (dextromethorphan/quinidine) (PDF)
  41. Neurontin (gabapentin) (PDF)
  42. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  43. Opiate Overutilization (PDF)
  44. Oxycodone Extended-Release Products (PDF)
  45. PDE5-Inhibitors (PDF)
  46. Promethazine/Promethazine Containing Products (PDF)
  47. Phosphate Binders (PDF)
  48. Propylthiouracil (PDF)
  49. Ranexa (PDF)
  50. Sickle Cell Agents (PDF)
  51. Symlin (pramlintide Acetate) (PDF)
  52. Synagis (palivizumab) (PDF)
  53. Thiazolidinediones (PDF)
  54. Topical Immunomodulators (PDF)
  55. Xifaxan (rifaximin) (PDF)
  56. Xyrem (PDF)