The Texas Medicaid formulary includes some drugs subject to one or both types of prior authorization, clinical and non-preferred. Prior authorization must be approved before the drug is dispensed. Prior authorization is not a guarantee of payment. Even if a drug has been prior authorized, reimbursement can be affected for a variety of reasons (e.g., the client is ineligible on the date of service or the claim transaction is incomplete). The pharmacy should verify client eligibility status before submitting claims.

Some drugs are subject to one or both types of prior authorization, clinical and non-preferred.

Clinical Prior Authorizations

• Drug Search
  • All drugs requiring clinical prior authorization
• Information
  • Medicaid Clinical Prior Authorization
    • About Traditional Medicaid clinical prior authorization
      • List of clinical prior authorizations
    • About Required MCO clinical prior authorizations
    • About Optional MCO clinical prior authorizations
      • List of clinical prior authorizations
  • CSHCN Services Program prior authorizations
• Documents
  • Medicaid Clinical Prior Authorization Assistance Chart
  • Medicaid Clinical Prior Authorization Criteria Documents
• Forms
  • Medicaid
  • CSHCN Services Program

Non-preferred Prior Authorizations

• Drug Search
  • All drugs requiring non-preferred prior authorization
• Information
  • About Medicaid non-preferred prior authorization
  • Preferred drug list process
• Documents
  • Preferred Drug List
  • Preferred Drug List Criteria Guide
  • Quarterly Tentative Drug Class Review Schedule
  • Preferred Drug List Recommendations
  • Preferred Drug List Decisions

Submitting Prior Authorization

• Submit prior authorization forms (some drugs require forms)
  • Medicaid managed care
  • Traditional Medicaid prior authorization request forms
  • CSHCN prior authorization request forms
• Request prior authorization
  • Medicaid managed care
  • Traditional Medicaid (clinical)
  • Traditional Medicaid (non-preferred)
  • CSHCN Services Program
• Learn how to submit a 72-hour emergency override for prescription claims
• Learn about the Texas Drug Utilization Review Board, the advisory group recommending changes to the preferred drug list and clinical prior authorization criteria