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
  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 and 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. Ketorolac (Toradol)
  41. Keveyis
  42. Leukotriene Modifiers
  43. Lidoderm (lidocaine) Patch
  44. Lovaza (omega-3-acid ethyl esters)
  45. Lyrica (pregabalin)
  46. Neurontin (gabapentin)
  47. Nuedexta (dextromethorphan/quinidine)
  48. Nuplazid
  49. Opiate Overutilization
  50. Opiate/Benzodiazepine/Muscle Relaxant Combinations
  51. Oxycodone Extended-Release Products
  52. PCSK9 Inhibitors
  53. Plavix (clopidogrel)
  54. Propylthiouracil
  55. Proton Pump Inhibitors (PDF)
  56. Provigil (modafinil)
  57. Pulmonary Arterial Hypertension
  58. Ranexa
  59. Revatio (sildenafil)
  60. Savella (milnacipran)
  61. Sitagliptin (Januvia)
  62. Suboxone/Subutex
  63. Symlin (pramlintide Acetate)
  64. Synagis (palivizumab)
  65. Thiazolidinediones
  66. Topical Acne Agents
  67. Topical Immunomodulators
  68. Victoza (liraglutide) Solution for Injection
  69. Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
  70. Xifaxan (rifaximin)
  71. Xyrem
  72. Zelboraf (vemurafenib)