Clinical Prior Authorization

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 health plan uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing.  This chart is updated quarterly.

  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. Buprenorphine Agents
  10. Carisoprodol
  11. Cough/Cold Medications
  12. COX-2 Inhibitors
  13. Cystic Fibrosis Agents
  14. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  15. Desmopressin
  16. Dextromethorphan Overutilization
  17. Drug Regimen Optimization
  18. Dupixent
  19. Duplicate Therapy
  20. Emflaza
  21. Erythropoiesis-Stimulating Agents
  22. Fentanyl Agents
  23. Flexeril/Amrix (cyclobenzaprine)
  24. GI Motility Agents
  25. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  26. Growth Hormones
  27. Hepatitis C Virus (Initial)
  28. Hepatitis C Virus (Refill)
  29. H.P. Acthar
  30. Imiquimod
  31. Increlex (mecasermin)
  32. Ketorolac (Toradol)
  33. Leukotriene Modifiers
  34. Lovaza (omega-3-acid ethyl esters)
  35. Nuedexta (dextromethorphan/quinidine) (PDF)
  36. Neurontin (gabapentin)
  37. Opiate/Benzodiazepine/Muscle Relaxant Combinations
  38. Opiate Overutilization
  39. Oxycodone Extended-Release Products
  40. PCSK9 Inhibitors
  41. Phenergan/Phenergan Containing Products (promethazine)
  42. Phosphate Binders (PDF)
  43. Propylthiouracil
  44. Provigil (modafinil)
  45. Ranexa
  46. Revatio (sildenafil)
  47. Sitagliptin (Januvia)
  48. Symlin (pramlintide Acetate)
  49. Synagis (palivizumab)
  50. Thiazolidinediones
  51. Topical Immunomodulators
  52. Victoza (liraglutide) Solution for Injection
  53. Xifaxan (rifaximin)
  54. 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 provider.