Refer to the clinical prior authorizations approved for use in Medicaid mananged care.

The following clinical prior authorizations apply to people enrolled in traditional Medicaid. Prescribing providers or their representatives should contact the Texas Pharmacy Prior Authorization Call Center at 1-877-PA-TEXAS (1-877-728-3927) to submit a prior authorization request. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing.

  1. ADD/ADHD Medications (PDF)
  2. Alinia (nitazoxanide) (PDF)
  3. Aliskiren-Containing Agents (except Valturna) (PDF)
  4. Allergen Extracts - Oralair (PDF)
  5. Altabax (retapamulin) (PDF)
  6. Antiemetics (PDF)
  7. Antipsychotics (PDF)
  8. Anxiolytics and Sedatives/Hypnotics (PDF)
  9. Buprenorphine Agents (PDF)
  10. Carisoprodol (PDF)
  11. Central Nervous System Stimulants (PDF)
  12. Cough/Cold Medications (PDF)
  13. COX-2 Inhibitors (PDF)
  14. Cystic Fibrosis Agents (PDF)
  15. Cytokine and CAM Antagonists (PDF)
  16. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  17. Desmopressin (PDF)
  18. Dextromethorphan Overutilization (PDF)
  19. Drug Regimen Optimization (PDF)
  20. Dupixent (PDF)
  21. Duplicate Therapy (PDF)
  22. Emflaza (PDF)
  23. Enzymes (PDF)
  24. Erythropoiesis-Stimulating Agents (PDF)
  25. Fentanyl Agents (PDF)
  26. Flexeril/Amrix (cyclobenzaprine) (PDF)
  27. GI Motility Agents (PDF)
  28. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  29. Growth Hormones (PDF)
  30. Hepatitis C Virus (Initial) (PDF)
  31. Hepatitis C Virus (Refill) (PDF)
  32. H.P. Acthar (PDF)
  33. Imiquimod (PDF)
  34. Increlex (mecasermin) (PDF)
  35. Ketorolac (Toradol) (PDF)
  36. Leukotriene Modifiers (PDF)
  37. Lovaza (omega-3-acid ethyl esters) (PDF)
  38. Nuedexta (dextromethorphan/quinidine) (PDF)
  39. Neurontin (gabapentin) (PDF)
  40. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  41. Opiate Overutilization (PDF)
  42. Oxycodone Extended-Release Products (PDF)
  43. PCSK9 Inhibitors (PDF)
  44. PDE5-Inhibitors (PDF)
  45. Promethazine/Promethazine Containing Products (PDF)
  46. Phosphate Binders (PDF)
  47. Propylthiouracil (PDF)
  48. Ranexa (PDF)
  49. Symlin (pramlintide Acetate) (PDF)
  50. Synagis (palivizumab) (PDF)
  51. Thiazolidinediones (PDF)
  52. Topical Immunomodulators (PDF)
  53. Xifaxan (rifaximin) (PDF)
  54. Xyrem (PDF)

The following drugs require prior authorization request forms:

  • Synagis
  • Xenical (orlistat)