Clinical Criteria
ADD/ADHD (Pending Implementation) (Revised July 11, 2022)*
ADD/ADHD Agents (Revised December 2, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised February 17, 2021)
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Pending Implementation) (Revised July 25, 2022)*
Allergen Extracts (Revised December 10, 2019)*
Altabax (Revised February 17, 2021)*
Amantadine ER (Pending Implementation) (Revised November 11, 2021)*
Androgenic Agents (Pending Implementation) (Revised March 21, 2019)*
Antiemetic Agents (Revised February 17, 2021)*
Antifungal Agents, Topical (Pending Implementation) (Revised October 22, 2021)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised January 21, 2022)*
Antipsychotic Agents (Pending Implementation) (Revised June 2, 2022)*
Antipsychotic Agents (Revised February 17, 2021)*
Antiseizure Agents (Epidiolex and Fintepla) (Pending Implementation) (July 25, 2022)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised July 8, 2022)*
Anxiolytics and Sedative-Hypnotics (Revised February 4, 2022)*
Arikayce (Pending Implementation) (Revised February 17, 2021)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised November 11, 2021)*
Buprenorphine Agents (Revised July 19, 2021)*
Carisoprodol Overuse (Revised March 26, 2019)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised May 23, 2019)*
CGRP Antagonists, Acute (Pending Implementation) (Revised January 24, 2022)*
CGRP Antagonists, Prophylaxis (Pending Implementation) (Revised February 17, 2022)*
Cholestatic Pruritis Agents (Pending Implementation) (Revised April 28, 2022)*
CNS Stimulants (Revised October 29, 2019)*
Colcrys (Pending Implementation) (Revised February 17, 2021)*
Cough & Cold Agents (Revised January 13, 2022)*
COX-2 Inhibitors (Revised February 18, 2021)*
Cyclobenzaprine (Revised October 6, 2020)*
Cymbalta (Pending Implementation) (Revised January 30, 2020)*
Cystic Fibrosis Agents (Pending Implementation) (Revised July 1, 2021)*
Cystic Fibrosis Agents (Revised January 20, 2021)
Cytokine and CAM Antagonists (Pending Implementation) (Revised May 23, 2022)*
Cytokine and CAM Antagonists (Revised January 28, 2022)*
Desmopressin (Revised December 21, 2020)*
Dextromethorphan Overutilization (Revised March 12, 2020)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diacomit (Pending Implementation) (Revised August 20, 2020)*
Diclofenac (Pending Implementation) (Revised March 27, 2019)*
Dopamine Agonists (Pending Implementation) (Revised January 22, 2021)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised October 29, 2019)*
DPP4 Inhibitors (Revised March 27, 2019)*
Drug Regimen Optimization (Pending Implementation) (Revised November 11, 2021)*
Drug Regimen Optimization (Revised September 16, 2019)*
Dupixent (Revised March 10, 2022)*
Duplicate Therapy (Revised June 9, 2022)*
Emflaza (Revised October 7, 2021)*
Enzymes (Pending Implementation) (Revised April 5, 2021)*
Enzymes (Revised September 11, 2019)*
Erythropoiesis-Stimulating Agents (Revised October 7, 2020)*
Evrysdi (Pending Implementation) (Revised June 9, 2022)*
Fentanyl Agents (Revised July 19, 2021)*
Forteo (Pending Implementation) (Revised March 29, 2019)*
Gabapentin Agents (Revised March 29, 2019)*
Gaucher's Disease Agents (Pending Implementation) (Revised July 15, 2019)*
GI Motility Agents (Pending Implementation) (Revised July 25, 2022)*
GI Motility Agents (Revised March 29, 2019)*
Glatiramer Acetate Injection (Pending Implementation) (Revised July 15, 2019)*
GLP-1 Receptor Agonists (Pending Implementation) (Revised August 9, 2021)*
GLP-1 Receptor Agonists (Revised June 1, 2021)*
Growth Hormone Agents (Pending Implementation) (Revised June 8, 2022)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Pending Implementation) (Revised July 1, 2021)*
Hemady (Pending Implementation) (Revised March 29, 2021)*
HP Acthar (Pending Implementation) (Revised July 24, 2020)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Revised October 7, 2021)*
Imiquimod (Revised March 29, 2019)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
Increlex (Revised March 29, 2019)*
Inhaled Antibiotics (Pending Implementation) (Revised February 13, 2020)*
Ketorolac (Revised March 29, 2019)*
Keveyis (Pending Implementation) (Revised March 29, 2019)*
Leukotriene Modifiers (Revised July 15, 2019)*
Lidocaine Patches (Pending Implementation) (Revised November 7, 2019)*
Lovaza (Revised February 17, 2022)*
Lupus Agents (Pending Implementation) (Revised October 22, 2021)*
Lyrica (Pending Implementation) (Revised March 7, 2022)*
Makena (Revised November 11, 2021)*
Monoclonal Antibody Agents (Pending Implementation) (Revised July 25, 2022)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
Multiple Sclerosis Agents (Pending Implementation) (Revised July 23, 2021)*
Nitazoxanide (Formerly Alinia) (Revised September 7, 2021)*
Nuedexta (Revised November 11, 2021)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Opiate Overutilization (Revised July 27, 2020)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised January 30, 2020)*
Oriahnn (Pending Implementation) (Revised October 28, 2020)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised July 24, 2020)*
Oxycontin / Narcotic Analgesic (Revised March 29, 2019)*
Palforzia (Pending Implementation) (Revised October 8, 2021)*
PDE5-Inhibitors (Revised October 6, 2021)*
Phosphate Binders (Revised February 2, 2022)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Promethazine Utilization (Revised October 19, 2021)*
Propylthiouracil (Revised March 29, 2019)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Pending Implementation) (Revised February 13, 2020)*
Pulmozyme (Pending Implementation) (Revised January 24, 2022)*
Qelbree (Pending Implementation) (Revised July 28, 2021)*
Ranexa (Revised March 29, 2019)*
Recorlev (Pending Implementation) (Revised April 22, 2022)*
Retinoids (Pending Implementation) (Revised July 19, 2021)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised August 1, 2022)*
Sickle Cell Agents (Revised February 17, 2022)*
Symlin (Revised March 29, 2019)*
Synagis (Revised June 1, 2022)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised July 19, 2021)*
Topical Immunomodulators (Pending Implementation) (Revised March 24, 2022)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised October 8, 2021)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised April 26, 2019)
Valturna (Retired) (Revised August 23, 2017)*
VMAT2 Inhibitors (Revised October 15, 2021)*
Voxzogo (Pending Implementation) (Revised April 22, 2022)*
Wakix (Pending Implementation) (Revised October 8, 2021)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised October 8, 2021)*
Xyrem/Xywav (Pending Implementation) (Revised October 8, 2021)*
Zelboraf (Pending Implementation) (Revised October 8, 2021)*
1 - 125
Hepatitis C Treatment Coverage and PDL Update Scheduled for September 1
by TALESHIA.CORE on 08/12/2022
Beginning September 1, 2022, Texas Medicaid will designate one medication as the primary preferred direct-acting antiviral (DAA) drug option for treating Hepatitis C infection. HHSC will designate all other DAA drugs on the Medicaid formulary as non-preferred. All Medicaid clients are eligible for DAA treatment with the primary preferred agent regardless of the client’s METAVIR fibrosis score, and prior authorization is not required. Any enrolled Medicaid provider can prescribe the preferred drug, and a drug screening is not required. HHSC will publish an update to the Texas Medicaid Preferred Drug List (PDL) on September 1, 2022, to designate preferred and non-preferred options for DAA treatment. Drugs identified on the PDL as preferred are available without prior authorization. To learn more, visit
Respiratory Syncytial Virus (RSV) Prophylaxis Season Reopening Across All Regions
by CHRISTINA.FAULKNER on 05/25/2022
The Texas Health and Human Services Commission (HHSC) is aware of a summertime RSV resurgence in multiple regions across the state. In response to the RSV activity and consultation with medical experts from across the state, HHSC will take necessary action to prevent the further spread of RSV by reopening all regions to monthly administration of palivizumab (Synagis) prophylaxis to eligible members, beginning June 1, 2022. Providers may start monthly palivizumab (Synagis) prophylaxis treatment for all eligible members starting as early as June 1. To learn more, visit
April 2022 Drug Utilization Review Board Meeting Summary
by CHRISTINA.FAULKNER on 05/05/2022
The Texas Drug Utilization Review Board met Friday, April 22, to make recommendations about clinical prior authorizations and drugs on the Texas Medicaid Preferred Drug List. To learn more, visit
Clinical Prior Authorization Criteria Updates for Dupixent, Evrysdi, and Qelbree
by TALESHIA.CORE on 07/01/2022
HHSC revised the following clinical prior authorization criteria guides to reflect the recent recommendations from the recent U.S. Food and Drug Administration (FDA) approved indications: • Dupixent (Dupilumab) in the Monoclonal Antibody Agents clinical prior authorization • Evrysdi (Risdiplam) • Qelbree (Vilozazine) in the Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) Medications prior authorization These clinical prior authorizations are not yet applicable to fee-for-service and are optional for managed care. To learn more, visit
March 2022 Specialty Drug List Available
by CHRISTINA.FAULKNER on 03/30/2022
The March 2022 biannual Specialty Drug List is now available. The SDL includes drugs MCOs may exclusively provide through their specialty pharmacy network. To learn more, visit
Changes for Client Access to Mosquito Repellent Benefit Begin June 1
by TALESHIA.CORE on 02/24/2022
Beginning May 31, 2022, HHSC will stop using the Texas Medicaid Standing Order for Mosquito Repellent. Pharmacies must obtain a prescription from a Medicaid-enrolled prescribing provider to dispense mosquito repellent beginning June 1, 2022, for Medicaid, Children’s Health Insurance Program (CHIP), and Healthy Texas Women (HTW). HHSC has extended the effective date of the current standing order until May 31, 2022, to ensure providers have adequate notice regarding upcoming changes to the mosquito repellent benefit. To learn more, visit
Oxbryta Prior Authorization Criteria Updates Scheduled for April 5
by TALESHIA.CORE on 02/17/2022
On April 5, 2022, HHSC will revise the prior authorization criteria in the Sickle Cell Disease Agents clinical prior authorization for Oxbryta (voxelotor) to ensure alignment with the US Food and Drug Administration-approved indications and package inserts. The criteria update includes the FDA’s recent age expansion to 4 years and older, and the removal of criteria step 6 relating to the drug interaction with CYP3A4 inhibitors or fluconazole. The updated criteria guide document also includes pediatric dosing information tables. This clinical prior authorization remains optional for managed care. To learn more, visit
Cytokine and CAM Antagonists Criteria Updates Scheduled for April 5
by CHRISTINA.FAULKNER on 02/16/2022
On April 5, 2022, HHSC will make the following revisions to various medications within the Cytokine and CAM Antagonists clinical prior authorization criteria to ensure alignment with US Food and Drug Administration approved indications. This clinical prior authorization remains optional for managed care. To learn more, visit
Updates to Phosphate Binder Prior Authorization Criteria Scheduled for April 5
by CHRISTINA.FAULKNER on 02/16/2022
On April 5, 2022, HHSC will revise the phosphate binder non-preferred prior authorization criteria by transferring specific criteria to the phosphate binders clinical prior authorization. This update correlates with the recent Texas Drug Utilization Review Board-approved revisions to the phosphate binder clinical prior authorization criteria. In this process, HHSC will also rearrange some of the steps to help improve the way each step flows into the next. The changes to the non-preferred prior authorization criteria are mandatory for MCOs. The phosphate binders clinical prior authorization remains optional for managed care. To learn more, visit