Clinical Prior Authorization

Managed care organizations have the option to use any clinical prior authorization that was approved by the Texas Drug Utilization Review Board.  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. Providers can also refer to our MCO Resources for links to each health plan's clinical prior authorizations.

Clinical prior authorizations that all health plans are required to perform include:

  1. Cystic Fibrosis Agents (PDF)
    • Only Orkambi criteria is required
  2. Hepatitis C Virus (initial) (PDF)
  3. Hepatitis C Virus (refill)(PDF)
  4. Promethazine Utilization, Age less than 2 years of age (PDF)
  5. Synagis (PDF)

Clinical prior authorizations that health plans have the option to perform include:

  1. ADD/ADHD Medications (PDF)
  2. Alinia (nitazoxanide) (PDF)
  3. Aliskiren-Containing Agents (except Valturna) (PDF)
  4. Allergen Extracts - Grastek/Oralair/Ragwitek (PDF)
  5. Altabax (retapamulin) (PDF)
  6. Androgenic Agents (PDF)
  7. Antipsychotics (PDF)
  8. Antiemetics (PDF)
  9. Anxiolytics and Sedatives/Hypnotics (PDF)
  10. Buprenorphine Agents (PDF)
  11. Carisoprodol (PDF)
  12. Colcrys (colchicine) (PDF)
  13. Copaxone (glatiramer) (PDF)
  14. Cough and Cold Medications (PDF)
  15. COX-2 Inhibitors (PDF)
  16. Cymbalta (duloxetine) (PDF)
  17. Cystic Fibrosis Agents (PDF)
  18. Cytokine and CAM Antagonists (PDF)
  19. Desmopressin (PDF)
  20. Dextromethorphan Overutilization (PDF)
  21. Diabetic Test Strips (PDF)
  22. Diclofenac (PDF)
  23. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  24. Drug Regimen Optimization (PDF)
  25. Dupixent (PDF)
  26. Duplicate Therapy (PDF)
  27. Emflaza (PDF)
  28. Enzymes (PDF)
  29. Erythropoiesis-Stimulating Agents (PDF)
  30. Fentanyl Agents (PDF)
  31. Flexeril/Amrix (cyclobenzaprine) (PDF)
  32. Forteo (teriparatide) (PDF)
  33. Gaucher's Disease Agents (PDF)
  34. GI Motility Agents (PDF)
  35. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  36. Growth Hormones (PDF)
  37. Hereditary Angioedema (PDF)
  38. H.P. Acthar (PDF)
  39. Imiquimod (PDF)
  40. Increlex (mecasermin) (PDF)
  41. Ketorolac (Toradol) (PDF)
  42. Keveyis (PDF)
  43. Leukotriene Modifiers (PDF)
  44. Lidoderm (lidocaine) Patch (PDF)
  45. Lovaza (omega-3-acid ethyl esters) (PDF)
  46. Lyrica (pregabalin) (PDF)
  47. Neurontin (gabapentin) (PDF)
  48. Nuedexta (dextromethorphan/quinidine) (PDF)
  49. Nuplazid (PDF)
  50. Opiate Overutilization (PDF)
  51. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  52. Oxycodone Extended-Release Products (PDF)
  53. PCSK9 Inhibitors (PDF)
  54. Phosphate Binders (PDF)
  55. Plavix (clopidogrel) (PDF)
  56. Propylthiouracil (PDF)
  57. Proton Pump Inhibitors (PDF)
  58. Provigil (modafinil) (PDF)
  59. Pulmonary Arterial Hypertension (PDF)
  60. Ranexa (PDF)
  61. Revatio (sildenafil) (PDF)
  62. Savella (milnacipran) (PDF)
  63. Sitagliptin (Januvia) (PDF)
  64. Symlin (pramlintide Acetate) (PDF)
  65. Synagis (palivizumab) (PDF)
  66. Thiazolidinediones (PDF)
  67. Topical Acne Agents (PDF)
  68. Topical Immunomodulators (PDF)
  69. Victoza (liraglutide) Solution for Injection (PDF)
  70. Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
  71. Xifaxan (rifaximin) (PDF)
  72. Xyrem (PDF)
  73. Zelboraf (vemurafenib) (PDF)