MCO Clinical Prior Authorization Comparison Chart Available

Each MCO has the option to develop their own algorithms for clinical prior authorization as long as it is no more stringent than the board-approved criteria. This Pharmacy Clinical Prior Authorization Assistance Chart (PDF) identifies which criteria are utilized by each MCO and how those criteria relate to those used by VDP.

Fee-For-Service Medicaid (TxPA)

Currently Implemented

The following criteria have been implemented for fee-for-service Medicaid clients and are maintained by the Texas pharmacy prior authorization website. Visit that site for forms and instructions on how to submit prior authorization requests by phone, fax, or the Texas Standard Prior Authorization Form.

Name Revised
Abestral     09/27/2011
Actiq (Oral Transmucosal Fentanyl) 02/07/2012
ADDADHD Medications 6/20/2014
Agents for Cystic Fibrosis 09/09/2015
Alinia (Nitazoxanide) 10/21/2011
Aliskiren-Containing Agents (except Valturna) 06/18/2012
Allergen Extracts - Grastek/Oralair/Ragwitek 02/27/2015
Alprazolam/Carisoprodol/Hydrocodone Combination 12/09/2013
Altabax (Retapamulin) 10/13/2011
Amitiza (Lubiprostone) 05/24/2013
Antiemetics 02/07/2013
Antipsychotics 03/23/2016
Anxiolytics and Sedatives/Hypnotics (ASHs) 05/28/2015
Byetta (Exenatide Injection) 03/05/2012
Carisoprodol 03/05/2012
Cough/Cold Medications 11/03/2015
COX-2 Inhibitors 11/18/2011
Desmopressin 10/25/2013
Dextromethorphan Overutilization 0718/2012
Drug Regimen Optimization 07/18/2012
Duplicate Therapy 12/27/2012
Duragesic (Fentanyl Transdermal) 12/01/2011
Erythropoiesis-Stimulating Agents 08/23/2013
Flexeril/Amrix (Cyclobenzaprine) 10/17/2011
Fosrenol (Lanthanum) 10/13/2011
Growth Hormones 10/21/2014
H.P. Acthar® 03/08/2016
Hepatitis C Virus (Initial) 04/08/2015
Hepatitis C Virus (Refill) 04/08/2015
Imiquimod 07/18/2012
Increlex (Mecasermin) 07/08/2014
Ketorolac (Toradol) 07/12/2012
Lazanda 09/27/2011
Lovaza (Omega-3-Acid Ethyl Esters) Capsules 08/10/2012
Leukotriene Modifiers 12/15/2015
Methylnaltrexone Bromide (Relistor) 08/23/2013
Neurontin (Gabapentin) 10/21/2011
Opiate Overutilization 10/04/2013
OxyContin (Oxycodone) 02/27/2015
Phenergan/Phenergan Containing Products (Promethazine) 10/13/2011
Propylthiouracil 10/13/2011
Provigil (Modafinil) 10/26/2012
Ranexa 04/03/2012
Revatio (Sildenafil) 02/27/2015
Sitaglipt (Januvia) 07/18/2012
Suboxone/Subutex 10/17/2014
Symlin (Pramlintide Acetate) 04/06/2012
Synagis (Palivizumab) 09/09/2015
Thiazolidinediones 03/06/2012
Topical Immunomodulators 04/24/2014
Valturna Agents 07/18/2012
Victoza (Liraglutide) Solution for Injection 07/18/2012
Xifaxan (Rifaximin) 10/21/2011
Xyrem 10/26/2011

DUR-Approved Criteria (Pending FFS Implementation)

The following criteria have been approved by the Drug Utilization Review (DUR) Board:

  • VDP will notify pharmacy providers once an implementation date has been set for fee-for-service Medicaid.
  • Health plans have the option to implement any clinical prior authorization criteria that has been approved by the board.
Name Updated
Actemra 04/10/2014
Agents for Gaucher's Disease 04/25/2014
Agents for GI Motility 04/29/2016
Agents for Hereditary Angioedema 04/10/2014
Androgenic agents 07/07/2014
Copaxone® (Glatiramer) 07/07/2014
Cymbalta® 01/24/2014
Cytokine and CAM Antagonists 11/25/2014
Duplicate Therapy 03/26/2014
Diabetic Test Strips   01/27/2016
Enzymes 05/16/2014
Fentanyl Agents                      10/14/2016
Fentora (fentanyl buccal) 06/02/2016
Forteo (Teriparatide) 08/16/2015
Injectable Pulmonary Hypertension Agents 11/24/2014
Lidocaine Patches 02/27/2015
Lyrica (Pregabalin) (PDF)
Nuedexta 01/27/2016
Opiate/benzodiazepine/muscle relaxant combination 08/08/2016
PCSK9 Inhibitors 10/22/2015
Plavix® 01/24/2014
Savella 10/22/2015
Topical Acne Agents 10/22/2015
Xenazine® 01/24/2014
Zelboraf® 01/08/2014

Medicaid Managed Care

Implementation of the DUR-approved criteria is at the discretion of each health plan (see list). Clients and pharmacy staff should verify with each health plan as to which criteria apply. Criteria that all health plans are required to perform:

Please refer to the MCO Resources page for links to each of the health plan’s clinical prior authorizations.

Fee-For-Service Medicaid (VDP Internal Review) 

The following criteria are for fee-for-service Medicaid clients and are reviewed by the Vendor Drug Program.

Name Form Updated
Adagen PDF 02/09/2004
Aldurazyme PDF 02/09/2004
Ceprotin PDF 02/09/2004
Cerezyme PDF 02/09/2004
Elaprase PDF 02/09/2004
Fabrazyme PDF 02/09/2004
Myozyme PDF 02/09/2004
Naglazyme PDF 02/09/2004
Orlistat PDF 02/09/2004
Lumizyme PDF 11/04/2014