Managed Care Clinical Prior Authorization

Spotlight

Refer to the clinical prior authorizations implemented in traditional Medicaid.

Managed care organizations have the option to use any clinical prior authorization approved by the Texas Drug Utilization Review Board. The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO 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 MCO Resources for links to each MCO's clinical prior authorizations.

Clinical prior authorizations required by MCOs to perform for people enrolled in Medicaid include:

  1. Hepatitis C Virus (PDF) (HHS Form 1335)
  2. Promethazine/Promethazine Containing Products (PDF)
  3. Synagis (PDF)

The following clinical prior authorizations are those MCOs have the option to perform for people enrolled in Medicaid or CHIP.

  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. Amantadine ER (PDF)
  7. Androgenic Agents (PDF)
  8. Antiemetics (PDF)
  9. Antifungal Agents, Topical (PDF)
  10. Antipsychotics (PDF)
  11. Anxiolytics and Sedatives/Hypnotics (PDF)
  12. Arikayce (PDF)
  13. Binge Eating Disorder (BED) Agents (PDF)
  14. Buprenorphine Agents (PDF)
  15. Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute (PDF)
  16. CGRP Antagonists, Chronic
  17. Carisoprodol Containing Agents (PDF)
  18. Carisoprodol Overuse (PDF)
  19. Central Nervous System Stimulants (PDF)
  20. Colcrys (colchicine) (PDF)
  21. Copaxone (glatiramer) (PDF)
  22. Cough and Cold Medications (PDF)
  23. COX-2 Inhibitors (PDF)
  24. Cyclobenzaprine (PDF)
  25. Cymbalta (duloxetine) (PDF)
  26. Cystic Fibrosis Agents (PDF)
  27. Cytokine and CAM Antagonists (PDF)
  28. Desmopressin (PDF)
  29. Dextromethorphan Overutilization (PDF)
  30. Diabetic Test Strips (PDF)
  31. Diacomit (PDF)
  32. Diclofenac (PDF)
  33. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
  34. Dopamine Agonists (PDF)
  35. Doxylamine/Pyridoxine (PDF)
  36. Drug Regimen Optimization (PDF)
  37. Dupixent (PDF)
  38. Duplicate Therapy (PDF)
  39. Emflaza (PDF)
  40. Epidiolex (PDF)
  41. Enzymes (PDF)
  42. Evrysdi (PDF)
  43. Erythropoiesis-Stimulating Agents (PDF)
  44. Fentanyl Agents (PDF)
  45. Flexeril/Amrix (cyclobenzaprine) (PDF)
  46. Forteo (teriparatide) (PDF)
  47. Gaucher's Disease Agents (PDF)
  48. GI Motility Agents (PDF)
  49. Glatiramer Acetate Injection (PDF)
  50. Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PDF)
  51. Growth Hormones (PDF)
  52. Hemady (PDF)
  53. Hereditary Angioedema (PDF)
  54. H.P. Acthar (PDF)
  55. Hyperlipidemia Agents (PDF)
  56. Imiquimod (PDF)
  57. Increlex (mecasermin) (PDF)
  58. Inhaled Antibiotics (PDF)
  59. Ketorolac (Toradol) (PDF)
  60. Keveyis (PDF)
  61. Leukotriene Modifiers (PDF)
  62. Lidocaine Patches (PDF)
  63. Lupus (PDF)
  64. Lovaza (omega-3-acid ethyl esters) (PDF)
  65. Lyrica (pregabalin) (PDF)
  66. Makena (PDF)
  67. Monoclonal Antibody Agents for Asthma (PDF)
  68. Multiple Sclerosis Agents (PDF)
  69. Neutontin (Gabapentin) Agents (PDF)
  70. Nuedexta (dextromethorphan/quinidine) (PDF)
  71. Nuplazid (PDF)
  72. Ophthalmic Immunomodulators (PDF)
  73. Opiate Overutilization (PDF)
  74. Opiate/Benzodiazepine/Muscle Relaxant Combinations (PDF)
  75. Oriahnn (PDF)
  76. Orilissa (PDF)
  77. Oxervate (PDF)
  78. Oxycodone Extended-Release Products (PDF)
  79. Palforzia (PDF)
  80. PCSK9 Inhibitors (PDF)
  81. Phosphodiesterase 5 (PDE5) Inhibitors (PDF)
  82. Phosphate Binders (PDF)
  83. Plavix (clopidogrel) (PDF)
  84. Propylthiouracil (PDF)
  85. Proton Pump Inhibitors (PDF)
  86. Quelbree (PDF)
  87. Retinoids (PDF)
  88. Pulmonary Arterial Hypertension (PDF)
  89. Ranexa (PDF)
  90. Savella (milnacipran) (PDF)
  91. Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (PDF)
  92. Sickle Cell Agents (PDF)
  93. Symlin (pramlintide Acetate) (PDF)
  94. Synagis (palivizumab) (PDF)
  95. Thiazolidinediones (PDF)
  96. Topical Acne Agents (PDF)
  97. Topical Immunomodulators (PDF)
  98. Topical Retinoids (PDF)
  99. Transthyretin Agents (PDF)
  100. Urea Cycle Disorder Agents (PDF)
  101. Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
  102. Wakix (PDF)
  103. Xifaxan (rifaximin) (PDF)
  104. Xyrem/Xyway PDF)
  105. Zelboraf (vemurafenib) (PDF)