Clinical Criteria
ADD/ADHD Agents (Revised March 2, 2021)*
Alinia (Revised February 17, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised February 17, 2021)
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Revised December 10, 2019)*
Altabax (Revised February 17, 2021)*
Amantadine ER (Pending Implementation) (Revised January 27, 2021)*
Androgenic Agents (Pending Implementation) (Revised March 21, 2019)*
Antiemetic Agents (Revised February 17, 2021)*
Antipsychotic Agents (Revised February 17, 2021)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised April 30, 2021)*
Anxiolytics and Sedative-Hypnotics (Revised March 22, 2019)*
Arikayce (Pending Implementation) (Revised February 17, 2021)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised March 1, 2021)*
Buprenorphine Agents (Revised March 22, 2019)*
Carisoprodol Overuse (Revised March 26, 2019)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised May 23, 2019)*
CGRP Antagonists, Acute (Pending Implementation) (Revised October 28, 2020)*
CGRP Antagonists, Chronic (Pending Implementation) (Revised August 29, 2019)*
CNS Stimulants (Revised October 29, 2019)*
Colcrys (Pending Implementation) (Revised February 17, 2021)*
Cough & Cold Agents (Revised March 10, 2020)*
COX-2 Inhibitors (Revised February 18, 2021)*
Cyclobenzaprine (Revised March 27, 2019)*
Cymbalta (Pending Implementation) (Revised January 30, 2020)*
Cystic Fibrosis Agents (Revised January 20, 2021)
Cytokine and CAM Antagonists (Revised March 2, 2021)*
Desmopressin (Revised December 21, 2020)*
Dextromethorphan Overutilization (Revised December 30, 2019)*
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, 2019)*
Drug Regimen Optimization (Revised September 16, 2019)*
Dupixent (Revised March 3, 2021)*
Duplicate Therapy (Revised April 27, 2021)*
Emflaza (Revised July 3, 2019)*
Enzymes (Pending Implementation) (Revised April 5, 2021)*
Enzymes (Revised September 11, 2019)*
Epidiolex (Pending Implementation May 11, 2021) (Revised February 25, 2021)*
Erythropoiesis-Stimulating Agents (Revised October 7, 2020)*
Evrysdi (Pending Implementation) (Revised January 22, 2021)*
Fentanyl Agents (Revised February 18, 2021)*
Forteo (Pending Implementation) (Revised March 28, 2019)*
Gabapentin Agents (Revised March 29, 2019)*
Gaucher's Disease Agents (Pending Implementation) (Revised July 15, 2019)*
GI Motility Agents (Pending Implementation) (Revised July 30, 2019)*
GI Motility Agents (Revised March 29, 2019)*
Glatiramer Acetate Injection (Pending Implementation) (Revised July 15, 2019)*
GLP-1 Receptor Agonists (Revised April 12, 2021)*
Growth Hormone Agents (Revised February 20, 2020)*
Growth Hormone Quick Reference Guide
HAE Agents (Pending Implementation) (Revised April 23, 2021)*
Hemady (Pending Implementation) (Revised March 29, 2021)*
HP Acthar (Pending Implementation) (Revised July 24, 2020)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Formerly PCSK9 Inhibitors) (Revised March 29, 2019)*
Hyperlipidemia Agents (Pending Implementation) (Revised April 23, 2021)*
Imiquimod (Revised March 29, 2019)*
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 July 15, 2019)*
Lovaza (Revised April 30, 2021)*
Lyrica (Pending Implementation) (Revised June 26, 2020)*
Makena (Revised May 14, 2019)*
Monoclonal Antibody Agents for Asthma (Revised February 1, 2021)*
Multiple Sclerosis Agents (Pending Implementation) (Revised April 23, 2021)*
Nuedexta (Revised March 29, 2019)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Ophthalmic Immunomodulators (Pending Implementation) (Revised June 30, 2020)*
Opiate Overutilization (Revised July 27, 2020)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised January 30, 2020)*
Opioid Policy Criteria (Formerly MME criteria) (Revised July 20, 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 August 24, 2020)*
PDE5-Inhibitors (Revised November 8, 2019)*
Phosphate Binders (Revised January 30, 2020)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Promethazine Utilization (Revised March 29, 2019)*
Propylthiouracil (Revised March 29, 2019)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Pending Implementation) (Revised February 13, 2020)*
Ranexa (Revised March 29, 2019)*
Retinoids (Pending Implementation) (Revised July 15, 2020)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised May 1, 2019)
Sickle Cell Agents (Revised January 30, 2020)*
Symlin (Revised March 29, 2019)*
Synagis (Revised August 11, 2020)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised February 1, 2021)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised April 24, 2020)
Urea Cycle Disorder Agents (Pending Implementation) (Revised April 26, 2019)
Valturna (Retired) (Revised August 23, 2017)*
VMAT2 Inhibitors (Revised June 24, 2020)*
Wakix (Pending Implementation) (Revised October 28, 2020)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised March 29, 2019)*
Xyrem/Xywav (Pending Implementation) (Revised October 28, 2020)*
Zelboraf (Pending Implementation) (Revised March 29, 2019)*
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Announcements
Enzymes Clinical Prior Authorization Criteria Revisions Effective June 30
by TANNER.BAIN on 04/21/2021
HHSC will revise the clinical prior authorization criteria guides for enzymes on June 30, 2021, per the recent US Food and Drug Administration changes. References to Adagen, Ceprotin, Fabrazyme, and Revcovi will change. To learn more, visit txvendordrug.com/about/news.
Revised Hepatitis C Drug Prior Authorization Form 1342
by TANNER.BAIN on 03/11/2021
On March 1, 2021, Medicaid expanded coverage to include Metavir fibrosis score F2 for Hepatitis C treatment. HHSC recently revised the “Antiviral Agents for Hepatitis C Virus Initial Request – Standard Prior Authorization Addendum” (HHS Form 1342). Prescribing providers must use this form along with the Standard Prior Authorization Request (TDI Form NOFR002) for people enrolled in fee-for-service Medicaid. To learn more, visit txvendordrug.com/about/news.
Revisions to Cytokine and CAM Antagonists Prior Authorization Criteria Set for May 4
by TANNER.BAIN on 03/05/2021
HHSC will revise Cytokine and Cell-Adhesion Molecule (CAM) Antagonists clinical prior authorizations criteria on May 4, 2021, in accordance with the recent US Food and Drug Administration changes. This clinical prior authorization is optional for MCOs. To learn more, visit txvendordrug.com/about/news.
Monoclonal Antibody for Asthma Prior Authorization Updates Set for April 6, 2021
by TANNER.BAIN on 02/11/2021
Fasenra (benralizumab) and Nucals (mepolizumab) are monoclonal antibody drugs approved for severe asthma treatment. On April 6, 2021, HHSC will make the following changes to the prior authorization criteria for Monoclonal Antibody Agents to enhance appropriate utilization per the US Food and Drug Administration’s approved indications and dosing. To learn more, visit txvendordrug.com/about/news.
Revised Hepatitis C Drug Prior Authorization Forms Now Available
by TANNER.BAIN on 02/11/2021
On March 1, 2021, Texas Medicaid will expand Hepatitis C virus clinical prior authorization criteria coverage to include Metavir fibrosis score F2 and require an escalation process for other Medicaid clients with severe extrahepatic effects of chronic Hepatitis C with a Metavir fibrosis score other than F2, F3, or F4. If a client does not meet the prior authorization criteria, but the prescribing provider determines treatment is required based on documentation of severe extrahepatic effects, then the escalation process would be necessary. Revised prior authorization forms are available for use with the new criteria. To learn more, visit txvendordrug.com/about/news.
Desmopressin Clinical Prior Authorization Revision Scheduled for March 15, 2021
by TANNER.BAIN on 01/04/2021
On March 15, 2021, HHSC will revise the desmopressin clinical prior authorization by removing the hyponatremia denial criteria. The change will allow approval for people whose hyponatremia has been resolved. This clinical prior authorization is optional for MCOs. To learn more, visit txvendordrug.com/about/news.
Change to Thiazolidinedione Clinical Prior Authorization Begins February 4
by TANNER.BAIN on 12/02/2020
Beginning February 4, 2021, Texas Medicaid will no longer subject Oseni, a combination of Thiazolidinediones (TZD) and Dipeptidyl Peptidase-4 inhibitor drug, to the TZD clinical prior authorization criteria. Oseni is not recommended for patients with severe renal impairment or end-stage renal disease requiring dialysis. Therefore, the TZD criteria are deemed inappropriate for this drug. Oseni will continue to be subject to the Dipeptidyl Peptidase-4 Inhibitors clinical prior authorization criteria. This prior authorization is optional for use in Medicaid managed care. To learn more, visit txvendordrug.com/about/news.
Clinical Prior Authorization Updates for Cystic Fibrosis Agents
by TANNER.BAIN on 01/29/2021
HHSC currently requires all MCOs to implement the Orkambi criteria of the current cystic fibrosis agents clinical prior authorization. On March 1, 2021, HHSC will update the clinical prior authorization, and all agents will be optional, with Orkambi no longer required. Also, the Food and Drug Administration recently expanded the indications for Kalydeco, Orkambi, Symdeko, and Trikafta. On April 6, 2021, HHSC will update the cystic fibrosis agents prior authorization criteria to reflect recent FDA-approved indication expansions. To learn more, visit txvendordrug.com/about/news.
Preferred Drug List Criteria Exception for Macrolides Changes March 15
by TANNER.BAIN on 01/29/2021
On March 15, 2021, HHSC will change the Preferred Drug List prior authorization criteria for the “Macrolides (oral)” PDL class. The new exception will allow the Food and Drug Administration-indicated shorter treatment duration for certain preferred products (such as azithromycin) before approval of a non-preferred option. HHSC will publish an update to the PDL Criteria Guide (PDF)(link is external) reflecting the change on March 15. To learn more, visit txvendordrug.com/about/news.
Dupixent Clinical Prior Authorization Criteria Revision Effective March 15
by TANNER.BAIN on 01/14/2021
On March 15, 2021, VDP will revise the Dupixent clinical prior authorization. Dupixent is FDA-approved for multiple indications, including the treatment of atopic dermatitis. VDP will update the current clinical prior authorization criteria for atopic dermatitis treatment to better align with the Preferred Drug List criteria. To learn more, visit txvendordrug.com/about/news.