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 < 2 (PDF)
  5. Synagis (PDF)

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

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