Clinical Criteria
ADD/ADHD Agents (Pending Implementation) (Revised January 26, 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 December 1, 2022)*
Allergen Extracts (Revised December 10, 2019)*
Altabax (Revised July 5, 2022)*
Amantadine ER (Pending Implementation) (Revised October 18, 2022)*
Androgenic Agents (Pending Implementation) (Revised December 20, 2022)*
Antiemetic Agents (Revised July 5, 2022)*
Antifungal Agents, Topical (Pending Implementation) (Revised October 22, 2021)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised October 31, 2022)*
Antipsychotic Agents (Pending Implementation) (Revised June 2, 2022)*
Antipsychotic Agents (Revised February 17, 2021)*
Antiseizure Agents (Epidiolex and Fintepla) (Pending Implementation) (Revised October 22, 2022)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised November 29, 2022)*
Anxiolytics and Sedative-Hypnotics (Revised February 4, 2022)*
Arikayce (Pending Implementation) (Revised July 5, 2022)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised November 11, 2021)*
Buprenorphine Agents (Revised July 19, 2021)*
Carisoprodol Overuse (Revised October 20, 2022)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised October 20, 2022)*
CGRP Antagonists, Acute (Pending Implementation) (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Revised December 1, 2022)*
Cholestatic Pruritis Agents (Pending Implementation) (Revised December 1, 2022)*
CNS Stimulants (Pending Implementation) (Revised January 26, 2023)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised May 24, 2022)*
Cough & Cold Agents (Revised November 18, 2022)*
COX-2 Inhibitors (Revised May 24, 2022)*
Cyclobenzaprine (Revised October 18, 2022)*
Cymbalta (Pending Implementation) (Revised October 18, 2022)*
Cystic Fibrosis Agents (Revised September 21, 2022)
Cytokine and CAM Antagonists (Pending Implementation) (Revised January 20, 2023)*
Cytokine and CAM Antagonists (Revised January 28, 2022)*
Desmopressin (Revised October 18, 2022)*
Dextromethorphan Overutilization (Revised November 18, 2022)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diacomit (Pending Implementation) (Revised October 22, 2022)*
Diclofenac (Pending Implementation) (Revised October 20, 2022)*
Dopamine Agonists (Pending Implementation) (Revised October 18, 2022)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised October 29, 2019)*
DPP4 Inhibitors (Revised March 27, 2019)*
Drug Regimen Optimization (Retired)*
Duplicate Therapy (Revised November 18, 2022)*
Emflaza (Revised October 7, 2021)*
Enzymes (Pending Implementation) (Revised October 18, 2022)*
Enzymes (Revised September 11, 2019)*
Erythropoiesis-Stimulating Agents (Revised October 28, 2022)*
Evrysdi (Pending Implementation) (Revised June 9, 2022)*
Fentanyl Agents (Revised December 20, 2022)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 28, 2022)*
Gaucher's Disease Agents (Pending Implementation) (Revised December 1, 2022)*
GI Motility Agents (Pending Implementation) (Revised October 18, 2022)
GI Motility Agents (Revised March 29, 2019)*
Glatiramer Acetate Injection (Pending Implementation) (Revised July 15, 2019)*
GLP-1 Receptor Agonists (Revised November 17, 2022)*
Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (Pending Implementation) (Revised September 12, 2022)*
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 November 16, 2022)*
Hemady (Pending Implementation) (Revised October 28, 2022)*
HP Acthar (Pending Implementation) (Revised December 2, 2022)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Revised October 7, 2021)*
Imiquimod (Revised October 19, 2022)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
Increlex (Revised October 19, 2022)*
Inhaled Antibiotics (Pending Implementation) (Revised October 28, 2022)*
Ketorolac (Revised October 28, 2022)*
Keveyis (Pending Implementation) (Revised October 28, 2022)*
Leukotriene Modifiers (Revised December 2, 2022)*
Lidocaine Patches (Pending Implementation) (Revised January 17, 2023)*
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 October 28, 2022)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
Monoclonal Antibody Agents - Dupixent (Revised March 10, 2022)*
Multiple Sclerosis Agents (Pending Implementation) (Revised January 20, 2023)*
Nitazoxanide (Formerly Alinia) (Revised September 7, 2021)*
Nitazoxanide (Pending Implementation) (Revised May 24, 2022)*
Nuedexta (Revised November 11, 2021)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Omega-3 Fatty Acids (Formerly Lovaza) (Revised February 17, 2022)*
Omega-3 Fatty Acids (Pending Implementation) (Revised January 3, 2023)*
Opiate Overutilization (Revised December 15, 2022)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Pending Implementation) (Revised January 20, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised December 15, 2022*)
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised December 2, 2022)*
Oxycodone Extended-Release Agents (Revised October 31, 2022)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised October 31, 2022)*
Phosphate Binders (Revised February 2, 2022)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Preferred Drug List (July 2022)
Promethazine Utilization (Revised October 19, 2022)*
Propylthiouracil (Revised October 31, 2022)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Pending Implementation) (Revised October 7, 2022)*
Pulmozyme (Pending Implementation) (Revised January 24, 2022)*
Qelbree (Pending Implementation) (Revised July 28, 2021)*
Ranexa (Revised October 31, 2022)*
Recorlev (Pending Implementation) (Revised April 22, 2022)*
Recurrent Vulvovaginal Candidiasis (RVVC) Agents (Vivjoa) (Pending Implementation) (Revised October 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 October 19, 2022)*
Symlin (Revised March 29, 2019)*
Synagis (Revised September 15, 2022)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised July 19, 2021)*
Topical Immunomodulators (Pending Implementation) (Revised January 20, 2023)*
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)*
Ztalmy (Pending Implementation) (Revised January 20, 2023)*
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Announcements
Changes to Lovaza Clinical Prior Authorization Scheduled for March 21, 2023
by TALESHIA.CORE on 01/19/2023
On March 21, HHSC will make revise the Lovaza prior authorization criteria, including changing its name to Omega-3 Fatty Acids. A list of changes is available on the Vendor Drug Program website. This clinical prior authorization is optional for managed care organizations. To learn more, visit txvendordrug.com/about/news.
Annual Review of Clinical Prior Authorization Criteria Guides to Begin; Changes Scheduled for February 7
by TALESHIA.CORE on 12/28/2022
HHSC initiated an annual internal review of specific clinical prior authorizations. A detailed list of revisions is available on the Vendor Drug Program website. All of these clinical prior authorizations are optional for MCOs. MCOs using these clinical prior authorizations must revise their criteria by February 7, 2023. To learn more, visit txvendordrug.com/about/news.
Clinical Prior Authorization Criteria Revisions for Bylvay Scheduled for November 21
by TALESHIA.CORE on 10/28/2022
HHSC will modify the prior authorization criteria for Bylvay in the Cholestatic Pruritis Agents clinical prior authorization criteria guide for clarification purposes to ensure the criteria approve patients with the appropriate diagnosis and comply with Food and Drug Administration-approved age indications. The Cholestatic Pruritis Agents clinical prior authorization is optional for MCOs. To learn more, visit txvendordrug.com/about/news.
Clinical Criteria Update for Orkambi Scheduled For November 9
by TALESHIA.CORE on 10/07/2022
On November 9, 2022, HHSC will implement the clinical prior authorization criteria updates for Orkambi (lumacaftor/ivacaftor). This change follows the U.S. Food and Drug Administration's (FDA) recent approval for age expansion. The Cystic Fibrosis Agents clinical prior authorization is optional for MCOs. To learn more, visit txvendordrug.com/about/news.
PDL Prior Authorization Criteria Revisions Scheduled For October 11
by TALESHIA.CORE on 09/22/2022
On October 11, 2022, HHSC will revise step one of the PDL prior authorization criteria guides for the Bronchodilators, Beta Agoniststs and Glucagon Agents drug class. These changes will modify the duration of treatment with a preferred agent per the Food and Drug Administration (FDA). The PDL prior authorization criteria are mandatory for managed care. Any changes must be implemented by the MCOs no later than October 11. To learn more, visit txvendordrug.com/about/news.
Hepatitis C Treatment Coverage and PDL Update Scheduled for 2023
by TALESHIA.CORE on 09/06/2022
On January 1, 2023, HHSC 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. HHSC originally announced these changes would occur on September 1, 2022. 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) 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 txvendordrug.com/about/news.