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. Cytokine and CAM Antagonists (PDF)
  15. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  16. Desmopressin
  17. Dextromethorphan Overutilization
  18. Drug Regimen Optimization
  19. Dupixent
  20. Duplicate Therapy
  21. Emflaza
  22. Erythropoiesis-Stimulating Agents
  23. Fentanyl Agents
  24. Flexeril/Amrix (cyclobenzaprine)
  25. GI Motility Agents (PDF)
  26. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  27. Growth Hormones
  28. Hepatitis C Virus (Initial)
  29. Hepatitis C Virus (Refill)
  30. H.P. Acthar
  31. Imiquimod
  32. Increlex (mecasermin)
  33. Ketorolac (Toradol)
  34. Leukotriene Modifiers
  35. Lovaza (omega-3-acid ethyl esters)
  36. Nuedexta (dextromethorphan/quinidine) (PDF)
  37. Neurontin (gabapentin)
  38. Opiate/Benzodiazepine/Muscle Relaxant Combinations
  39. Opiate Overutilization
  40. Oxycodone Extended-Release Products
  41. PCSK9 Inhibitors
  42. PDE5-Inhibitors (PDF)
  43. Promethazine/Promethazine Containing Products (PDF)
  44. Phosphate Binders (PDF)
  45. Propylthiouracil
  46. Provigil (modafinil)
  47. Ranexa
  48. Sitagliptin (Januvia)
  49. Symlin (pramlintide Acetate)
  50. Synagis (palivizumab)
  51. Thiazolidinediones
  52. Topical Immunomodulators
  53. Victoza (liraglutide) Solution for Injection
  54. Xifaxan (rifaximin)
  55. 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.