MCO Clinical Prior Authorization Comparison Chart Available

Each MCO has the option to develop their own algorithms for clinical prior authorization as long as it is no more stringent than the board-approved prior authorization. This Pharmacy Clinical Prior Authorization Assistance Chart (PDF) identifies which clinical prior authorizations are utilized by each MCO and how they relate to those used in traditional Medicaid.

Clinical Prior Authorization

The following clinical prior authorizations apply to people enrolled in traditional Medicaid (fee for service).  Prescribing providers or their representatives should contact the Texas Pharmacy Prior Authorization Call Center to submit a prior authorization request.

  1. ADD/ADHD Medications
  2. Alinia (nitazoxanide)
  3. Aliskiren-Containing Agents (except Valturna)
  4. Allergen Extracts - Grastek/Oralair/Ragwitek
  5. Altabax (retapamulin)
  6. Antiemetics
  7. Antipsychotics
  8. Anxiolytics and Sedatives/Hypnotics
  9. Byetta (exenatide) Injection
  10. Carisoprodol
  11. Cough/Cold Medications
  12. COX-2 Inhibitors
  13. Cystic Fibrosis Agents
  14. Desmopressin
  15. Dextromethorphan Overutilization
  16. Drug Regimen Optimization
  17. Dupixent
  18. Duplicate Therapy
  19. Emflaza
  20. Erythropoiesis-Stimulating Agents
  21. Fentanyl Agents
  22. Flexeril/Amrix (cyclobenzaprine)
  23. Fosrenol (lanthanum)
  24. GI Motility Agents
  25. Growth Hormones
  26. Hepatitis C Virus (Initial)
  27. Hepatitis C Virus (Refill)
  28. H.P. Acthar
  29. Imiquimod
  30. Increlex (mecasermin)
  31. Ketorolac (Toradol)
  32. Leukotriene Modifiers
  33. Lovaza (omega-3-acid ethyl esters)
  34. Nuedexta (dextromethorphan/quinidine) (PDF)
  35. Neurontin (gabapentin)
  36. Opiate/Benzodiazepine/Muscle Relaxant Combinations
  37. Opiate Overutilization
  38. Oxycodone Extended-Release Products
  39. PCSK9 Inhibitors
  40. Phenergan/Phenergan Containing Products (promethazine)
  41. Propylthiouracil
  42. Provigil (modafinil)
  43. Ranexa
  44. Revatio (sildenafil)
  45. Sitagliptin (Januvia)
  46. Suboxone/Subutex
  47. Symlin (pramlintide Acetate)
  48. Synagis (palivizumab)
  49. Thiazolidinediones
  50. Topical Immunomodulators
  51. Victoza (liraglutide) Solution for Injection
  52. Xifaxan (rifaximin)
  53. Xyrem

The following drugs require prior authorization request forms.  Providers and pharmacy staff should use either form #1 or #2 to and submit the completed form as instructed.  All submissions must be from the prescribing physician..