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HHSC Has Updated Clinical Prior Authorization Criteria Guides

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The Texas Health and Human Services Commission (HHSC) reviewed and updated the clinical prior authorization criteria guides listed below. The Opioid Clinical Policy criterion is required for all Medicaid managed care organizations (MCOs). All other clinical prior authorizations are optional for MCOs. HHSC will notify pharmacies when we implement criteria for fee-for-service Medicaid claims.

The following clinical prior authorization criteria guides have been updated:

  • ADD/ADHD Agents
  • Allergen Extracts
  • Antiemetic Agents
  • Antimigraine Agents-Triptans
  • Antipsychotic Agents
  • Anxiolytics/Sedatives/Hypnotics (ASH)
  • Buprenorphine Agents
  • Colchicine
  • Cortisol Receptor Antagonist (previously named Recorlev)
  • COX2 Inhibitors
  • Cytokine and CAM Antagonists
  • Desmopressin
  • Diclofenac
  • DPP4 Inhibitors
  • Dopamine Agonists
  • Enzymes
  • Fentanyl Agents
  • Forteo
  • GI Motility Agents
  • GLP-1 Receptor Agonists
  • HP Acthar
  • Ileal Bile Acid Transporter (IBT) Inhibitors
  • Imiquimod
  • Ketorolac
  • Leukotriene Modifiers
  • Lyrica
  • Monoclonal Antibody Agents
  • Multiple Sclerosis
  • Omega-3 Fatty Acids
  • Opiate/Benzodiazepine/Muscle Relaxant Combinations
  • Opiate Overutilization
  • Opioid Clinical Policy
  • Oxycodone Extended Release Agents
  • Pulmonary Hypertension Agents
  • Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors

The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO’s prior authorizations and how these authorizations relate to those that are used for processing fee-for-service Medicaid claims. This chart is updated quarterly. Providers can refer to the MCO Search for links to each MCO’s list of clinical prior authorizations.

Email vdp-formulary@hhsc.state.tx.us with comments or any questions.