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Some Updated Clinical Prior Authorization Criteria Guides Now Available

Last updated on

The Texas Health and Human Services Commission (HHSC) has reviewed and updated some clinical prior authorization criteria guides.

The following guides have been updated:

  • Allergen Extracts
  • Antimigraine Agents, Ergot
  • Antiseizure Agents
  • Anxiolytics and Sedatives/Hypnotics (ASHs)
  • Biliary Cholangitis Agents
  • Buprenorphine Agents
  • Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute
  • Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis
  • Corticotropin
  • Cough and Cold Medications
  • Cystic Fibrosis Agents
  • Cytokine and CAM Antagonists
  • Dextromethorphan Overutilization
  • Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
  • Doxylamine/Pyridoxine
  • Duchenne Muscular Dystrophy Agents
  • Duplicate Therapy
  • Eohilia
  • Gaucher’s Disease Agents
  • Glatiramer
  • HAE Agents
  • Hyperlipidemia Agents
  • Imcivree
  • Immunomodulators, Topical
  • Leukotriene Modifiers
  • Lidocaine Patch
  • Lupus Agents
  • Monoclonal Antibody Agents
  • Nuplazid
  • Opioid Policy Criteria
  • Opiate/Benzodiazepine/Muscle Relaxant Combinations
  • Oxervate
  • Oxybate Products
  • PDE-5 Inhibitors
  • Promethazine Agents
  • Pulmonary Hypertension Agents
  • Recurrent Vulvovaginal Candidiasis (RVVC) Agents
  • Skyclarys
  • Symlin
  • Thiazolidinediones
  • Topical Antifungals for Onychomycosis
  • Transthyretin Agents
  • Xyrem
  • Xifaxan
  • Zelboraf

Managed care organizations (MCOs) can implement these clinical prior authorization criteria at their discretion.

The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorizations that each MCO has implemented and how they relate to prior authorizations that are used for processing fee-for-service Medicaid claims. This chart is updated quarterly.

HHSC will notify pharmacies and prescribers when any of these prior authorization criteria are implemented for Medicaid fee-for-service.

Email vdp-formulary@hhs.texas.gov with comments or any questions.