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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.

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

Ambetter from Superior HealthPlan

Medicaid

Current Preferred Drug List

Medicare

Learn more about Medicare prescription drug coverage here.