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Opioid Policy Criteria
Opioid Clinical Policy (MME and day supply limits) (Revised September 17, 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 5, 2024)*
ADD/ADHD Agents (Revised September 5, 2024)*
Aliskiren Containing Agents (Pending Implementation) (Revised July 5, 2022)*
Aliskiren Containing Agents (Revised September 3, 2024)*
Allergen Extracts (Pending Implementation) (Revised May 30, 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 May 1, 2024)*
Antiemetic Agents (Revised July 5, 2022)*
Antifungal Agents, Topical (Pending Implementation) (Revised September 18, 2024)*
Antimigraine Agents, Ergot Derivatives (Revised January 9, 2024)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised September 18, 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) (Revised September 18, 2024)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised May 16, 2024)*
Anxiolytics and Sedative-Hypnotics (Revised July 18, 2023)*
Appetite Suppressant Agents (Pending Implementation) (Revised August 19, 2024)*
Arikayce (Pending Implementation) (Revised July 5, 2022)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised February 13, 2024)*
Buprenorphine Agents (Revised September 18, 2024)*
Carisoprodol Overuse (Revised June 30, 2024)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised June 30, 2024)*
CGRP Antagonists, Acute (Pending Implementation) (Revised January 9, 2024)*
CGRP Antagonists, Acute (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Pending Implementation) (Revised July 26, 2024)*
CGRP Antagonists, Prophylaxis (Revised January 9, 2024)*
CNS Stimulants (Pending Implementation) (Revised June 30, 2024)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised January 26, 2024)*
Cortisol Receptor Antagonists (Pending Implementation) (Revised June 30, 2024)*
Cough & Cold Agents (Revised February 28, 2023)*
COX-2 Inhibitors (Revised May 24, 2022)*
Cyclobenzaprine (Revised May 1, 2024)*
Cymbalta (Pending Implementation) (Revised May 1, 2024)*
Cystic Fibrosis Agents (Revised July 31, 2024)*
Cytokine and CAM Antagonists (Pending Implementation) (Revised October 1, 2024)*
Cytokine and CAM Antagonists (Revised September 6, 2024)*
Daybue (Revised July 21, 2023)*
Desmopressin (Pending Implementation) (Revised May 1, 2024)*
Desmopressin (Revised February 1, 2023)*
Dextromethorphan Overutilization (Revised July 31, 2024)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diclofenac (Pending Implementation) (Revised June 30, 2024)*
Dopamine Agonists (Pending Implementation) (Revised May 8, 2024)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised July 31, 2024)*
DPP4 Inhibitors (Revised October 15, 2024)*
Drug Regimen Optimization (Retired)*
Duplicate Therapy (Revised July 15, 2024)*
Emflaza (Revised September 18, 2024)*
Enzymes (Pending Implementation) (Revised May 8, 2024)*
Enzymes (Revised October 18, 2022)*
Eohilia (Pending Implementation) (Revised July 26, 2024)*
Erythropoiesis-Stimulating Agents (Pending Implementation) (June 30, 2024)*
Erythropoiesis-Stimulating Agents (Revised October 28, 2022)*
Evrysdi (Pending Implementation) (Revised August 5, 2024)*
Fentanyl Agents (Revised June 10, 2024)*
Filspari (Pending Implementation) (Revised October 13, 2023)*
FMT Agents (Pending Implementation) (Revised July 26, 2023)*
Forteo (Pending Implementation) (Revised May 9, 2024)*
Gabapentin Agents (Pending Implementation) (Revised June 30, 2024)*
Gabapentin Agents (Revised October 30, 2023)*
Gattex (Revised February 13, 2024)*
Gaucher's Disease Agents (Revised January 9, 2024)*
GI Motility Agents (Pending Implementation) (Revised June 10, 2024)*
GI Motility Agents (Revised June 10, 2024)*
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 July 25, 2024)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Revised January 11, 2024)*
Hemady (Pending Implementation) (Revised June 30, 2024)*
Hormonal Therapy Agents (Pending Implementation) (Revised May 28, 2024)*
Hormonal Therapy Agents (Revised December 26, 2023)*
HP Acthar (Pending Implementation) (Revised August 16, 2024)*
HP Acthar (Revised August 16, 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 (Pending Implementation) (Revised May 9, 2024)*
Imiquimod (Revised December 13, 2023)*
Immunomodulator Agents for Dry Eye (Pending Implementation) (Revised June 25, 2024)*
Increlex (Revised October 19, 2022)*
Inhaled Antibiotics (Revised June 30, 2024)*
Ketorolac (Revised June 30, 2024)*
Keveyis (Pending Implementation) (Revised June 30, 2024)*
Leukotriene Modifiers (Revised January 9, 2024)*
Lidocaine Patches (Pending Implementation) (Revised January 9, 2024)*
Lupus Agents (Pending Implementation) (Revised July 3, 2024)*
Lyrica (Pending Implementation) (Revised July 31, 2024)*
Monoclonal Antibody Agents (Pending Implementation) (Revised October 1, 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 July 31, 2024)*
Omega-3 Fatty Acids (Revised September 13, 2023)*
Opiate Overutilization (Revised September 17, 2024)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised September 17, 2024)*
Orilissa (Pending Implementation) (Revised February 16, 2024)*
Oxervate (Pending Implementation) (Revised January 10, 2024)*
Oxybate Products (Pending Implementation) (Revised July 31, 2024)*
Oxycodone Extended-Release Agents (Revised June 10, 2024)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised June 30, 2024)*
Phosphate Binders (Revised July 31, 2024)*
Plavix (Revised July 31, 2024) (Criteria retired November 10, 2024)*
Preferred Drug List (January 2024)*
Promethazine Utilization (Revised May 14, 2024)*
Propylthiouracil (Revised June 30, 2024)*
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 June 30, 2024)*
Recurrent Vulvovaginal Candidiasis (RVVC) Agents (Pending Implementation) (Revised September 18, 2024)*
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 (October 17, 2024 - Retired due to product recall)*
Skyclarys (Pending Implementation) (Revised October 13, 2023)*
Sphingosine 1-phosphate (S1P) Receptor Modulators (Pending Implementation) (Revised April 26, 2024)*
Symlin (Revised July 31, 2024)*
Synagis (Revised September 11, 2024)*
Thiazolidinediones (Revised July 31, 2024)*
Topical Acne Agents (Pending Implementation) (Revised February 23, 2024)*
Topical Immunomodulators (Pending Implementation) (Revised May 14, 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 August 16, 2024)*
VMAT2 Inhibitors (Revised August 16, 2024)*
Voxzogo (Pending Implementation) (Revised July 25, 2024)*
Wegovy (Pending Implementation) (Revised October 25, 2024)*
Xifaxan (Revised July 31, 2024)*
Xyrem (Revised February 1, 2023)*
Zelboraf (Revised July 31, 2024)*
Ztalmy (Pending Implementation) (Revised February 23, 2024)*
Zurzuvae (Pending Implementation) (Revised July 26, 2024)*
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