The Texas Medicaid formulary includes some drugs subject to one or both types of prior authorization, clinical and non-preferred. Prior authorization must be approved before the drug is dispensed. Prior authorization is not a guarantee of payment. Even if a drug has been prior authorized, reimbursement can be affected for a variety of reasons (e.g., the client is ineligible on the date of service or the claim transaction is incomplete). The pharmacy should verify client eligibility status before submitting claims.

Some drugs are subject to one or both types of prior authorization, clinical and non-preferred.

Learn about the Texas Drug Utilization Review Board, the advisory group recommending changes to clinical prior authorization criteria and the preferred drug list.

Clinical Prior Authorizations

• Drug Search
  • All drugs requiring clinical prior authorization
• Information
  • Clinical Prior Authorizations for Traditional Medicaid
  • Clinical Prior Authorizations for Managed Care
• Documents
  • Medicaid Clinical Prior Authorization Assistance Chart
  • Medicaid Clinical Prior Authorization Criteria Documents
• Forms
  • Medicaid
  • CSHCN Services Program

Non-preferred Prior Authorizations

• Drug Search
  • All drugs requiring non-preferred prior authorization
• Documents
  • Preferred Drug List
  • Preferred Drug List Criteria Guide
  • Quarterly Tentative Drug Class Review Schedule
  • Preferred Drug List Recommendations
  • Preferred Drug List Decisions

Requesting Prior Authorization

• Request prior authorization
  • Medicaid managed care
  • Traditional Medicaid
  • CSHCN Services Program
• Learn how to submit a 72-hour emergency override for prescription claims