Clinical Prior Authorization - Managed Care

Refer to the clinical prior authorizations implemented in traditional Medicaid.

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.

Required

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

  1. Hepatitis C Virus (PDF)
  2. Promethazine/Promethazine Containing Products (PDF)
  3. Synagis (PDF)

Refer to the Required MCO Clinical Prior Authorizations section for more information.

Optional

The following clinical prior authorizations are those MCOs have the option to perform for people 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. Androgenic Agents (PDF)
  7. Antiseizure Agents, Epidiolex and Fintepla (PDF)
  8. Antiemetics (PDF)
  9. Antifungal Agents, Topical (PDF)
  10. Antimigraine Agents, Triptans (PDF)
  11. Antipsychotics (PDF)
  12. Anxiolytics and Sedatives/Hypnotics (PDF)
  13. Arikayce (PDF)
  14. Binge Eating Disorder (BED) Agents (PDF)
  15. Buprenorphine Agents (PDF)
  16. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute (PDF)
  17. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis (PDF)
  18. Carisoprodol Containing Agents (PDF)
  19. Carisoprodol Overuse (PDF)
  20. Central Nervous System Stimulants (PDF)
  21. Cholestatic Pruritis Agents (PDF)
  22. Colcrys (colchicine) (PDF)
  23. Copaxone (glatiramer) (PDF)
  24. Cough and Cold Medications (PDF)
  25. COX-2 Inhibitors (PDF)
  26. Cyclobenzaprine (PDF)
  27. Cymbalta (duloxetine) (PDF)
  28. Cystic Fibrosis Agents (PDF)
  29. Cytokine and CAM Antagonists (PDF)
  30. Desmopressin (PDF)
  31. Dextromethorphan Overutilization (PDF)
  32. Diabetic Test Strips (PDF)
  33. Diacomit (PDF)
  34. Diclofenac (PDF)
  35. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  36. Dopamine Agonists (PDF)
  37. Doxylamine/Pyridoxine (PDF)
  38. Duplicate Therapy (PDF)
  39. Emflaza (PDF)
  40. Enzymes (PDF)
  41. Evrysdi (PDF)
  42. Erythropoiesis-Stimulating Agents (PDF)
  43. Fentanyl Agents (PDF)
  44. Flexeril/Amrix (cyclobenzaprine) (PDF)
  45. Forteo (teriparatide) (PDF)
  46. Gaucher's Disease Agents (PDF)
  47. GI Motility Agents (PDF)
  48. Glatiramer Acetate Injection (PDF)
  49. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  50. Growth Hormones (PDF)
  51. Hemady (PDF)
  52. Hereditary Angioedema (PDF)
  53. H.P. Acthar (PDF)
  54. Hyperlipidemia Agents (PDF)
  55. Imiquimod (PDF)
  56. Immunomodulator Agents for Dry Eye (PDF)
  57. Increlex (mecasermin) (PDF)
  58. Inhaled Antibiotics (PDF)
  59. Ketorolac (Toradol) (PDF)
  60. Keveyis (PDF)
  61. Leukotriene Modifiers (PDF)
  62. Lidocaine Patches (PDF)
  63. Lupus (PDF)
  64. Lovaza (omega-3-acid ethyl esters) (PDF)
  65. Lyrica (pregabalin) (PDF)
  66. Makena (PDF)
  67. Monoclonal Antibody Agents (PDF)
  68. Multiple Sclerosis Agents (PDF)
  69. Neutontin (Gabapentin) Agents (PDF)
  70. Nitazoxanide (PDF)
  71. Nuedexta (dextromethorphan/quinidine) (PDF)
  72. Nuplazid (PDF)
  73. Ophthalmic Immunomodulators (PDF)
  74. Opiate Overutilization (PDF)
  75. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  76. Oriahnn (PDF)
  77. Orilissa (PDF)
  78. Oxervate (PDF)
  79. Oxycodone Extended-Release Products (PDF)
  80. Palforzia (PDF)
  81. Phosphodiesterase 5 (PDE5) Inhibitors (PDF)
  82. Phosphate Binders (PDF)
  83. Plavix (clopidogrel) (PDF)
  84. Pulmozyme (PDF)
  85. Propylthiouracil (PDF)
  86. Proton Pump Inhibitors (PDF)
  87. Quelbree (PDF)
  88. Retinoids (PDF)
  89. Pulmonary Arterial Hypertension (PDF)
  90. Ranexa (PDF)
  91. Recorlev (levoketoconazole) (PDF)
  92. Recurrent Vulvovaginal Candidiasis (RVVC) Agents (PDF)
  93. Savella (milnacipran) (PDF)
  94. Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (PDF)
  95. Sickle Cell Agents (PDF)
  96. Symlin (pramlintide Acetate) (PDF)
  97. Synagis (palivizumab) (PDF)
  98. Thiazolidinediones (PDF)
  99. Topical Acne Agents (PDF)
  100. Topical Immunomodulators (PDF)
  101. Topical Retinoids (PDF)
  102. Transthyretin Agents (PDF)
  103. Urea Cycle Disorder Agents (PDF)
  104. Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
  105. Voxzogo (vosorititde) (PDF)
  106. Wakix (PDF)
  107. Xifaxan (rifaximin) (PDF)
  108. Xyrem/Xyway PDF)
  109. Zelboraf (vemurafenib) (PDF)