Clinical Prior Authorization
The following clinical prior authorizations have been implemented for Medicaid members, consistent with the Vendor Drug Program guidance. For any clinical edits that are required they are implemented as written by VDP. For any optional edits and if the plan has implemented, then they are implemented as written by VDP or may have eased criteria elements as noted. Reference: Managed Care Clinical Prior Authorization | Vendor Drug Program (txvendordrug.com). Please click on each link to see exact requirements.
- Acthar Gel (PDF)
- ADD/ADHD Agents (PDF)
- Aliskiren-Containing Agents (Except Valturna) (PDF)
- Allergen Extracts – Oralair (PDF)
- Amantadine ER (PDF)
- Androgenic Agents (PDF)
- Antiemetics (PDF)
- Antimigraine Agents, Triptans (PDF)
- Antipsychotics (PDF)
- Antiseizure Agents, Epidiolex and Fintepla (PDF)
- Anxiolytics and Sedatives/Hypnotics (ASHs) (PDF)
- Arikayce (PDF)
- Binge Eating Disorder (BED) Agents (PDF)
- Buprenorphine Agents (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment) (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Chronic) (PDF)
- Carisoprodol-Containing Agents (PDF)
- Cholestatic Pruritus Agents (PDF)
- CNS Stimulants (PDF)
- Colchicine Agents (PDF)
- Cough/Cold Medication (PDF)
- Cyclobenzaprine (PDF)
- Cymbalta (PDF)
- Cystic Fibrosis Agents (PDF)
- Cytokine and CAM Antagonists (PDF)
- Desmopressin (PDF)
- Dextromethorphan Overutilization (PDF)
- Diacomit (Stiripentol) (PDF)
- Diclofenac (PDF)
- Dipeptidyl Peptidase-4 (PDF)
- Dopamine Agonists (PDF)
- Doxylamine/Pyridoxine (PDF)
- Emflaza (PDF)
- Enzymes (PDF)
- Erythropoiesis-Stimulating Agents (PDF)
- Evrysdi (Risdiplam) (PDF)
- Fentanyl (PDF)
- Forteo (PDF)
- Gabapentin Agents- Horizant and Gralise (PDF)
- Gaucher’s Disease Agents (PDF)
- GI Motility Agents (PDF)
- Glatiramer Acetate Injection (PDF)
- Glucagon-Like Peptide (GLP-1) Receptor Agonists (PDF)
- Growth Hormone Products (PDF)
- Hemady (Dexamethasone) (PDF)
- Hepatitis C Antiviral Agents (PDF)
- Hereditary Angioedema (PDF)
- Hyperlipidemia Agents (PDF)
- Imiquimod (PDF)
- Immunomodulator Agents for Dry Eye (PDF)
- Increlex (PDF)
- Inhaled Antibiotics (PDF)
- Keveyis (PDF)
- Leukotriene Modifiers (PDF)
- Lidocaine Patch (PDF)
- Lovaza (PDF)
- Lupus Agents (PDF)
- Lyrica (PDF)
- Makena (PDF)
- Monoclonal Antibody Agents for Asthma (PDF)
- Multiple Sclerosis (MS) Agents (PDF)
- Nitazoxanide (PDF)
- Nuedexta (PDF)
- Nuplazid (PDF)
- Opioid Policy Criteria (PDF)
- Oriahnn (Elagolix, Estradiol, and Norethinedrone) (PDF)
- Orilissa (PDF)
- Oxervate (PDF)
- Palforzia (PDF)
- Phosphate Binders (PDF)
- Phosphodiesterase Type 5 (PDE-5) Inhibitors (PDF)
- Promethazine Agents (PDF)
- Proton Pump Inhibitors (PDF)
- Propylthiouracil (PDF)
- Pulmonary Arterial Hypertension (PDF)
- Pulmozyme (dornase alfa) (PDF)
- Ranexa (PDF)
- Recorlev (levoketoconazole) (PDF)
- Savella (PDF)
- SGLT2 Inhibitor Agents (PDF)
- Sickle Cell Disease Agents (PDF)
- Symlin (PDF)
- Synagis (PDF)
- Thiazolidinediones (PDF)
- Topical Acne Agents (PDF)
- Topical Antifungals for Onychomycosis (PDF)
- Topical Immunomodulators (PDF)
- Transthyretin Agents (PDF)
- Urea Cycle Disorder Agents (PDF)
- Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
- Voxzogo (vosoritide) (PDF)
- Wakix (Pitolisant) (PDF)
- Xifaxan (PDF)
- Xyrem/Xywav (PDF)
- Zelboraf (PDF)
The following clinical prior authorizations have not been implemented for Medicaid members at this time. Once implemented, a link to the clinical edit criteria will be provided.
- Altabax
- Carisoprodol Overuse
- Cox-2 Inhibitors
- Drug Regimen Optimization
- Duplicate Therapy
- Ketorolac (Toradol)
- Opiate/Benzodiazepine/Muscle Relaxant Combinations
- Opiate Overutilization
- Oxycontin (Narcotic Analgesic)
- Plavix
- Topical Retinoids