Pharmacy Prior Authorization
The Texas Medicaid formulary includes all legend and over-the-counter drugs. In addition, some vitamins and minerals and home health supply products are also available as a pharmacy benefit. Some Medicaid drugs are 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). Pharmacy staff should verify client eligibility status before submitting claims.
Clinical Prior Authorization
Clinical prior authorizations are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. They may apply to an individual drug or a drug class on the formulary, including some preferred and non-preferred drugs. There are certain clinical prior authorizations that all Medicaid managed care organizations (MCO) are required to perform. Usage of all other clinical prior authorizations will vary between MCO at the discretion of each MCO.
- The Clinical PA Assistance Chart (PDF) shows the prior authorizations that each MCO uses and those used for traditional Medicaid
Non-preferred Prior Authorization
The Texas Medicaid Preferred Drug List (PDL) is arranged by drug class and contains a subset of many, but not all, drugs that are on the Medicaid formulary. Drugs are identified as preferred or non-preferred on the PDL. Drugs listed on the PDL as preferred, or those not listed at all, are available to individuals without PDL prior authorization. Drugs identified as non-preferred on the PDL require a PDL prior authorization. Managed care organizations are required to adhere to the Texas Medicaid Preferred Drug List. CHIP does not have a PDL.
- The PDL PA Criteria Guide (PDF) explains the criteria used to evaluate the PDL PA requests
Obtaining PDL/Clinical Prior Authorization
Prescribing providers or their representatives should contact one of the following authorization authorities:
For Medicaid Managed Care
- Pharmacy prior authorization call centers vary by MCO. The Prescriber Assistance Chart (PDF) identifies each MCO and its prior authorization and member call center phone numbers.
For traditional Medicaid
- The Texas PA Call Center accepts prior authorization requests by phone at 1-877-PA-TEXAS (1-877-728-3927) or online. Please note online submission at PAXpress is only available for PDL prior authorization requests.
- Note: Xenical and Enzyme Replacement Therapy products require prior authorization but are reviewed internally by Texas Medicaid staff.
Drug Utilization Review Board
The Texas Drug Utilization Review Board develops recommendations for the preferred drug list, suggests clinical prior authorizations on outpatient prescription drugs, recommends educational interventions for Medicaid providers, and reviews prospective and retrospective drug utilization across the Medicaid program.
- For Medicaid managed care: MCO Prescriber Resources
- For Traditional Medicaid: Texas Prior Authorization Call Center
PDL PA Resources