Clinical Prior Authorization Criteria
Clinical prior authorizations perform real-time reviews of a Medicaid client’s medical and drug claims histories.
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)
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.
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.
|Agents for Gaucher's Disease||04/25/2014|
|Agents for GI Motility||04/29/2016|
|Agents for Hereditary Angioedema||04/10/2014|
|Cytokine and CAM Antagonists||11/25/2014|
|Diabetic Test Strips||01/27/2016|
|Fentora (fentanyl buccal)||06/02/2016|
|Injectable Pulmonary Hypertension Agents||11/24/2014|
|Lyrica (Pregabalin) (PDF)
|Opiate/benzodiazepine/muscle relaxant combination||08/08/2016|
|Topical Acne Agents||10/22/2015|
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.
The following criteria are for fee-for-service Medicaid clients and are reviewed by the Vendor Drug Program.