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Opioid Policy Criteria
Opioid Clinical Policy (MME and day supply limits) (Revised February 14, 2024)*
Standard PA Form and Addendums FFS
Texas Standard Prior Authorization Form for Prescription Drug Benefits
Cystic Fibrosis Addendum
Emflaza Addendum
Increlex Addendum
Oxycontin Addendum
PCSK9 Inhibitor Addendum
Phosphate Binders Addendum (non-preferred agents only)
Synagis Addendum to Standard PA Form
Xyrem Addendum
Forms (Fee-For-Service Medicaid Only)
PCSK9 Inhibitors Prior Authorization Form
PDL
Preferred Drug List (PDL)
PDL Criteria Guide
Documents and Help
Request for Reconsideration Form
Having Trouble Viewing or Downloading a Form?
TX-Phone-Number
For assistance with Fee For Service
PA requests only, call the Prior
Authorization Call Center
at 1-877-PA-TEXAS (1-877-728-3927)
Managed-Care
Patient member of Medicaid Managed Care Organization (MCO)?
Clinical Criteria
ADD/ADHD Agents (Pending Implementation) (Revised September 14, 2023)*
ADD/ADHD Agents (Revised December 2, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised July 5, 2022)*
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Pending Implementation) (Revised January 9, 2024)*
Allergen Extracts (Revised December 10, 2019)*
ALS Agents (Pending Implementation) (Revised July 21, 2023)*
Altabax (Revised July 5, 2022)*
Amantadine ER (Pending Implementation) (Revised February 28, 2024)*
Androgenic Agents (Pending Implementation) (Revised December 20, 2022)*
Antiemetic Agents (Revised July 5, 2022)*
Antifungal Agents, Topical (Pending Implementation) (Revised December 8, 2023)*
Antimigraine Agents, Ergot Derivatives (Revised January 9, 2024)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised January 26, 2024)*
Antimigraine Agents, Triptans (Revised March 7, 2024)*
Antipsychotic Agents (Pending Implementation) (Revised April 19, 2024)*
Antipsychotic Agents (Revised May 15, 2024)*
Antiseizure Agents (Diacomit, Epidiolex, and Fintepla) (Pending Implementation) (Revised December 8, 2023)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised May 16, 2024)*
Anxiolytics and Sedative-Hypnotics (Revised July 18, 2023)*
Appetite Suppressant Agents (Pending Implementation) (Revised April 27, 2024)*
Arikayce (Pending Implementation) (Revised July 5, 2022)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised February 13, 2024)*
Buprenorphine Agents (Revised December 8, 2023)*
Carisoprodol Overuse (Revised October 20, 2022)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised October 30, 2023)*
CGRP Antagonists, Acute (Pending Implementation) (Revised January 9, 2024)*
CGRP Antagonists, Acute (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Revised January 9, 2024)*
CNS Stimulants (Pending Implementation) (Revised October 30, 2023)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised January 26, 2024)*
Cough & Cold Agents (Revised February 28, 2023)*
COX-2 Inhibitors (Revised May 24, 2022)*
Cyclobenzaprine (Revised October 18, 2022)*
Cymbalta (Pending Implementation) (Revised October 18, 2022)*
Cystic Fibrosis Agents (Revised December 8, 2023)*
Cytokine and CAM Antagonists (Pending Implementation) (Revised May 15, 2024)*
Cytokine and CAM Antagonists (Revised May 15, 2024)*
Daybue (Pending Implementation) (Revised July 21, 2023)*
Desmopressin (Revised February 1, 2023)*
Dextromethorphan Overutilization (Revised December 8, 2023)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diclofenac (Pending Implementation) (Revised February 20, 2024)*
Dopamine Agonists (Pending Implementation) (Revised October 18, 2022)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised December 8, 2023)*
DPP4 Inhibitors (Revised December 8, 2023)*
Drug Regimen Optimization (Retired)*
Duplicate Therapy (Revised March 11, 2024)*
Emflaza (Revised December 8, 2023)*
Enzymes (Revised October 18, 2022)*
Erythropoiesis-Stimulating Agents (Pending Implementation) (Revised April 28, 2023)*
Erythropoiesis-Stimulating Agents (Revised October 28, 2022)*
Evrysdi (Pending Implementation) (Revised June 9, 2022)*
Fentanyl Agents (Revised March 21, 2023)*
Filspari (Pending Implementation) (Revised October 13, 2023)*
FMT Agents (Pending Implementation) (Revised July 26, 2023)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 30, 2023)*
Gattex (Revised February 13, 2024)*
Gaucher's Disease Agents (Revised January 9, 2024)*
GI Motility Agents (Revised October 10, 2023)*
Glatiramer Acetate Injection (Pending Implementation) (Revised January 9, 2024)*
GLP-1 Receptor Agonists (Revised August 9, 2023)*
Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (Pending Implementation) (Revised September 12, 2022)*
Growth Hormone Agents (Pending Implementation) (Revised February 13, 2024)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Revised January 11, 2024)*
Hemady (Pending Implementation) (Revised October 30, 2023)*
Hormonal Therapy Agents (Pending Implementation) (Revised May 28, 2024)*
Hormonal Therapy Agents (Revised December 26, 2023)*
HP Acthar (Pending Implementation) (Revised December 2, 2022)*
HP Acthar (Revised January 9, 2024)*
Hyperlipidemia Agents (Revised January 9, 2024)*
Ileal Bile Acid Transporter (IBAT) Inhibitors (Pending Implementation) (Revised January 9, 2024)*
Imcivree (Pending Implementation) (Revised October 13, 2023)*
Imiquimod (Revised December 13, 2023)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
Increlex (Revised October 19, 2022)*
Inhaled Antibiotics (Revised October 31, 2023)*
Ketorolac (Revised October 31, 2023)*
Keveyis (Pending Implementation) (Revised October 31, 2023)*
Leukotriene Modifiers (Revised January 9, 2024)*
Lidocaine Patches (Pending Implementation) (Revised January 9, 2024)*
Lupus Agents (Pending Implementation) (Revised February 14, 2024)*
Lyrica (Pending Implementation) (Revised December 8, 2023)*
Monoclonal Antibody Agents (Pending Implementation) (Revised May 9, 2024)*
Monoclonal Antibody Agents (Revised May 9, 2024)*
Monoclonal Antibody Agents - Dupixent (Revised March 10, 2022)*
Multiple Sclerosis Agents (Pending Implementation) (Revised June 1, 2023)*
Nitazoxanide (Formerly Alinia) (Revised September 7, 2021)*
Nitazoxanide (Pending Implementation) (Revised May 24, 2022)*
Nuedexta (Revised February 14, 2024)*
Nuplazid (Pending Implementation) (Revised December 8, 2023)*
Omega-3 Fatty Acids (Revised September 13, 2023)*
Opiate Overutilization (Revised November 8, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised February 13, 2024)*
Orilissa (Pending Implementation) (Revised February 16, 2024)*
Oxervate (Pending Implementation) (Revised January 10, 2024)*
Oxybate Products (formerly Xyrem/Xywav) (Pending Implementation) (Revised December 8, 2023)*
Oxycodone Extended-Release Agents (Revised November 9, 2023)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised February 28, 2024)*
Phosphate Binders (Revised February 7, 2024)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Preferred Drug List (January 2024)*
Promethazine Utilization (Revised October 19, 2022)*
Propylthiouracil (Revised October 31, 2022)*
Proton Pump Inhibitors (Pending Implementation) (Revised February 16, 2024)*
Pulmonary Hypertension Agents (Revised May 6, 2024)*
Pulmozyme (Pending Implementation) (Revised February 16, 2024)*
Ranexa (Revised October 31, 2022)*
Recorlev (Pending Implementation) (Revised December 13, 2023)*
Recurrent Vulvovaginal Candidiasis (RVVC) Agents (Pending Implementation) (Revised December 8, 2023)*
Retinoids (Pending Implementation) (February 23, 2024)*
Rezurock (Pending Implementation) (Revised October 13, 2023)*
Savella (Pending Implementation) (Revised February 20, 2024)*
SGLT2 Inhibitors (Pending Implementation) (Revised February 20, 2024)*
SGLT2 Inhibitors (Revised August 1, 2023)*
Sickle Cell Agents (Revised October 19, 2022)*
Skyclarys (Pending Implementation) (Revised October 13, 2023)*
Sphingosine 1-phosphate (S1P) Receptor Modulators (Pending Implementation) (Revised April 26, 2024)*
Symlin (Revised December 8, 2023)*
Synagis (Revised January 11, 2024)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised February 23, 2024)*
Topical Immunomodulators (Pending Implementation) (Revised March 7, 2024)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised January 10, 2024)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised February 23, 2024)*
Valturna (Retired) (Revised August 23, 2017)*
Veozah (Pending Implementation) (Revised August 14, 2023)*
VMAT2 Inhibitors (Pending Implementation) (Revised May 21, 2024)*
VMAT2 Inhibitors (Revised May 15, 2024)*
Voxzogo (Pending Implementation) (Revised February 20, 2024)*
Xifaxan (Revised December 8, 2023)*
Xyrem (Revised February 1, 2023)*
Zelboraf (Revised December 8, 2023)*
Ztalmy (Pending Implementation) (Revised February 23, 2024)*
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