Clinical Prior Authorizations

Clinical prior authorization edits are based on evidence-based clinical criteria and nationally recognized peer-reviewed information.  Before a prescription is filled, edits check a client’s Medicaid medical and drug claims histories to determine whether the information on file indicates that the client’s medical condition matches the edit criteria for dispensing the requested drug without need of additional prior authorization.  Prescriptions found to be in conflict with client records based on clinical edit criteria will require a prior authorization request by the prescriber before it can be filled by the pharmacist.

DUR Criteria

The DUR Board determines the therapeutic criteria and standards used in the retrospective and prospective programs, based on the compendia and peer reviewed medical literature.  Criteria and standards are periodically revised to ensure that they reflect prescribing recommendations of the current compendia and literature.

Drug Utilization Review Board

The Texas Drug Utilization Review Board is an advisory board to HHSC and consists of practicing physicians and pharmacists who are appointed by the HHSC Executive Commissioner. The DUR Board reviews and approves the therapeutic criteria for prospective DUR, retrospective DUR, and clinical prior authorization edits.  Board meetings are held quarterly in Austin.