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). 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 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 Prior Authorization Assistance Chart shows the prior authorizations used by each MCO and those used for traditional Medicaid.
Non-preferred Prior Authorization
The Texas Medicaid Preferred Drug List is arranged by drug class and contains a subset of many, but not all, drugs included on the Medicaid formulary. Drugs are identified as preferred or non-preferred on the list. Drugs listed as preferred, or those not listed at all, are available without prior authorization. Drugs identified as non-preferred require prior authorization. Managed care organizations are required to adhere to the preferred drug list. CHIP does not have a preferred drug list.
- The PDL Prior Authorization Criteria Guide (PDF) explains the criteria used to evaluate the PDL prior authorization requests
Obtaining Prior Authorization
Some drugs require prior authorization forms:
- Medicaid managed care
- Traditional Medicaid prior authorization request forms
- CSHCN prior authorization request forms
Prescribing providers or their representatives should contact one of the following:
- Medicaid managed care
- Traditional Medicaid (clinical)
- Traditional Medicaid (non-preferred)
- CSHCN Services Program
72-hour Emergency Overrides
72-hour emergency overrides apply to non-preferred drugs on the preferred drug list or drugs subject to clinical prior authorization. Pharmacies will be paid in full for 72-hour emergency prescription claims. Refer to the Emergency Override section in the Pharmacy Provider Procedure Manual for information about submitting a 72-hour emergency prescription claim.
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.