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Clinical Prior Authorization Criteria Revisions Implement for Medicaid Fee-for-Service October 26, 2022

Last updated on 9/28/2022

The Texas Health and Human Services Commission (HHSC) has revised the clinical criteria for anxiolytics and sedatives/hypnotics (ASH), attention deficit disorder/attention-deficit hyperactivity disorder (ADD/ADHD), and Qelbree prior authorizations based on recent U.S. Food and Drug Administration (FDA) approved indications.

HHSC will implement the revisions on October 26, 2022, for Medicaid fee-for-service.

Revisions include the following:

  • For the ASH clinical prior authorization criteria:
    • Removed ICD-10 code: F13.90 "Sedative, Hypnotic, or Anxiolytic Use, Unspecified, Uncomplicated" from the History of Substance Abuse Diagnoses supporting table
  • For the ADD/ADHD clinical prior authorization criteria:
    • Added drugs to the Drug Requiring Prior Authorization supporting table:
      • Amphetamine ER 1.25 mg/mL suspension (GCN 43864)
      • Methylphenidate ER capsules (GCNs: 97234, 97235, 97236, 97237, 97238, 97239, 97240)
      • Methylphenidate LA (GCNs: 20387, 20388, 20391)
    • Removed step checking for diagnosis of ADD/ADHD for nonstimulant agents prescribed for patients 18 years of age or older
  • For Qelbree (viloxazine), expanded the age check to clients 6 years of age or older

The ASH and ADD/ADHD clinical prior authorizations are optional for managed care organizations (MCOs). The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO's prior authorizations and how those authorizations relate to those used for processing fee-for-service Medicaid claims. The chart is updated quarterly. Providers can also refer to MCO Resources for links to each MCO's list of clinical prior authorizations.

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