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 or visit the TX vendor drug website. Please click on each link to see exact requirements.
- ADD/ADHD Agents (PDF)
- Aliskiren-Containing Agents (Except Valturna) (PDF)
- Allergen Extracts (PDF)
- Amantadine ER (PDF)
- Amyotrophic Lateral Sclerosis (ALS) Agents (PDF)
- Androgenic Agents (PDF)
- Antiemetics Agents (PDF)
- Antifungal Agents, Topical (PDF)
- Antimigraine Agents, Ergot Derivatives (PDF)
- Antimigraine Agents, Triptans (PDF)
- Antipsychotics Agents (PDF)
- Antiseizure Agents (PDF)
- Anxiolytics and Sedatives/Hypnotics (ASHs) (PDF)
- Appetite Suppressant Agents (PDF)
- Arikayce (PDF)
- Binge Eating Disorder (BED) Agents (PDF)
- Biliary Cholangitis Agents (PDF)
- Buprenorphine Agents (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment) (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis (PDF)
- Carisoprodol-Containing Agents (PDF)
- CNS Stimulants (PDF)
- Colchicine Agents (PDF)
- Cortisol Receptor Antagonists (PDF)
- Cough/Cold Medication (PDF)
- Cyclobenzaprine (PDF)
- Cymbalta (PDF)
- Cystic Fibrosis Agents (PDF)
- Cytokine and CAM Antagonists (PDF)
- Daybue (Trofinetide) (PDF)
- Desmopressin (PDF)
- Dextromethorphan Overutilization (PDF)
- Diclofenac (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
- Dopamine Agonists (PDF)
- Doxylamine/Pyridoxine (PDF)
- Duplicate Therapy (PDF)
- Enzymes (PDF)
- Eohilia (PDF)
- Erythropoiesis-Stimulating Agents (PDF)
- Evrysdi (Risdiplam) (PDF)
- Fecal Microbiota Transplantation (FMT) Agents (PDF)
- Fentanyl (PDF)
- Filspari (PDF)
- Forteo (PDF)
- Gabapentin Agents- Horizant and Gralise (PDF)
- Gattex (teduglutide) (PDF)
- Gaucher’s Disease Agents (PDF)
- GI Motility Agents (PDF)
- Glatiramer Acetate Injection (PDF)
- Glucagon-Like Peptide (GLP-1) Receptor Agonists (PDF)
- Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (PDF)
- Growth Hormone Products (PDF)
- Hemady (Dexamethasone) (PDF)
- Hereditary Angioedema (HAE) Agents (PDF)
- Hormonal Therapy Agents (PDF)
- HP Acthar (PDF)
- Hyperlipidemia Agents (PDF)
- Imcivree (PDF)
- Imiquimod (PDF)
- Immunomodulator Agents for Dry Eye (PDF)
- Increlex (PDF)
- Inhaled Antibiotics (PDF)
- Ketorolac (PDF)
- Keveyis (PDF)
- Leukotriene Modifiers (PDF)
- Lidocaine Patch (PDF)
- Lupus Agents (PDF)
- Lyrica (PDF)
- Monoclonal Antibody Agents (PDF)
- Multiple Sclerosis (MS) Agents (PDF)
- Nitazoxanide (PDF)
- Nuedexta (PDF)
- Nuplazid (PDF)
- Omega-3 Fatty Acids (PDF)
- Opioid Policy Criteria (PDF)
- Orilissa (PDF)
- Oxervate (PDF)
- Oxybate Products (PDF)
- Phosphate Binders (PDF)
- Phosphodiesterase Type 5 (PDE-5) Inhibitors (PDF)
- Promethazine Utilization (PDF)
- Proton Pump Inhibitors (PDF)
- Propylthiouracil (PDF)
- Pulmonary Hypertension Agents (PDF)
- Pulmozyme (dornase alfa) (PDF)
- Ranexa (PDF)
- Rezurock (PDF)
- Savella (PDF)
- SGLT2 Inhibitor Agents (PDF)
- Sphingosine 1-phosphate (S1P) Receptor Modulators (PDF)
- Skyclarys (PDF)
- Symlin (PDF)
- Synagis (PDF)
- Systemic Corticosteroids (PDF)
- Thiazolidinediones (PDF)
- Topical Acne Agents (PDF)
- Topical Immunomodulators (PDF)
- Transthyretin Agents (PDF)
- Urea Cycle Disorder Agents (PDF)
- Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
- Veozah (Fezolinetant) (PDF)
- Voxzogo (vosoritide) (PDF)
- Wegovy (PDF)
- Xifaxan (PDF)
- Yorvipath (PDF)
- Zelboraf (PDF)
- Zepbound (PDF)
- Zoryve (PDF)
- Ztalmy (Ganaxolone) (PDF)
- Zurzuvae (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
- Diabetic Test Strips
- Opiate/Benzodiazepine/Muscle Relaxant Combinations
- Opiate Overutilization
- Oxycontin (Narcotic Analgesic)
- Plavix
- Topical Retinoids
Ambetter from Superior HealthPlan
Medicaid
- Texas Medicaid PDL (preferred drug list) Aug 8 2024 (PDF)
- TX HHSC PDL (preferred drug list) Criteria Guide Aug 8 2024 (PDF)