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 September 20, 2023)*
Allergen Extracts (Revised December 10, 2019)*
ALS Agents (Pending Implementation) (Revised July 21, 2023)*
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, Ergot Derivatives (Revised April 28, 2023)*
Antimigraine Agents, Triptans (Revised February 8, 2023)*
Antipsychotic Agents (Pending Implementation) (Revised July 27, 2023)*
Antipsychotic Agents (Revised February 17, 2021)*
Antiseizure Agents (Diacomit, Epidiolex and Fintepla) (Pending Implementation) (Revised February 8, 2023)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised July 18, 2023)*
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 February 28, 2023)*
Carisoprodol Overuse (Revised October 20, 2022)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised October 20, 2022)*
CGRP Antagonists, Acute (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Revised May 18, 2023)*
CNS Stimulants (Pending Implementation) (Revised February 1, 2023)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised May 24, 2022)*
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 (Pending Implementation) (Revised September 13, 2023)*
Cystic Fibrosis Agents (Revised September 21, 2022)
Cytokine and CAM Antagonists (Revised August 11, 2023)*
Daybue (Pending Implementation) (Revised July 21, 2023)*
Desmopressin (Revised February 1, 2023)*
Dextromethorphan Overutilization (Revised February 28, 2023)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
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 (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)*
FMT Agents (Pending Implementation) (Revised July 26, 2023)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 28, 2022)*
Gattex (Revised April 28, 2023)*
Gaucher's Disease Agents (Pending Implementation) (Revised December 1, 2022)*
GI Motility Agents (Pending Implementation) (Revised July 7, 2023)*
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, 2023)*
GLP-1 Receptor Agonists (Revised August 2, 2023)*
Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (Pending Implementation) (Revised September 12, 2022)*
Growth Hormone Agents (Pending Implementation) (Revised July 21, 2023)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Revised March 23, 2023)*
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)*
Ileal Bile Acid Transporter (IBAT) Inhibitors (Formerly Cholestatic Pruritis Agents) (Pending Implementation) (Revised March 30, 2023)*
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 (Revised October 28, 2022)*
Ketorolac (Revised September 13, 2023)*
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)*
Monoclonal Antibody Agents (Pending Implementation) (Revised March 23, 2023)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
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 November 11, 2021)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Omega-3 Fatty Acids (Pending Implementation) (Revised September 13, 2023)*
Omega-3 Fatty Acids (Revised January 3, 2023)*
Opiate Overutilization (Revised March 22, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Pending Implementation) (Revised July 26, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised February 28, 2023)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised December 2, 2022)*
Oxycodone Extended-Release Agents (Revised March 22, 2023)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised May 15, 2023)*
Phosphate Binders (Revised February 1, 2023)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Preferred Drug List (July 2023)
Promethazine Utilization (Revised October 19, 2022)*
Propylthiouracil (Revised October 31, 2022)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Revised May 18, 2023)*
Pulmozyme (Pending Implementation) (Revised January 24, 2022)*
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 September 12, 2023)*
SGLT2 Agents (Revised February 1, 2023)*
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 May 17, 2023)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised October 8, 2021)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised July 7, 2023)
Valturna (Retired) (Revised August 23, 2017)*
Veozah (Pending Implementation) (Revised August 14, 2023)*
VMAT2 Inhibitors (Pending Implementation) (Revised June 1, 2023)*
VMAT2 Inhibitors (Revised October 15, 2021)*
Voxzogo (Pending Implementation) (Revised April 22, 2022)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised October 8, 2021)*
Xyrem/Xywav (Pending Implementation) (Revised October 8, 2021)*
Zelboraf (Revised October 8, 2021)*
Ztalmy (Pending Implementation) (Revised January 20, 2023)*
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HHSC To Implement Clinical Prior Authorizations For Fee-For-Service on Oct. 31
by CHRISTINA.FAULKNER on 08/31/2023
HHSC has reviewed and will update some clinical prior authorization criteria guides on October 31, 2023. These clinical prior authorizations are optional for the MCOs. To learn more, visit
Reminder: Client Access to Mosquito Repellents Available Through Pharmacy
by TALESHIA.CORE on 07/21/2023
The Centers for Disease Control and Prevention reported in June about locally acquired malaria cases being identified in Texas. To prevent and control the spread of malaria and other mosquito-borne diseases in Texas, HHSC reminds providers of the mosquito repellent pharmacy benefit. HHSC covers mosquito repellents year-round for the prevention of mosquito-borne diseases for clients enrolled in Medicaid, the Children's Health Insurance Program (CHIP), the Children with Special Health Care Needs (CSHCN) Services Program, and the Healthy Texas Women (HTW) Program. Coverage of mosquito repellent is limited to two cans or bottles per calendar month, and all programs require a prescription. Clients can contact their healthcare provider to obtain a prescription for mosquito repellent. To learn more, visit
Clinical Prior Authorizations Updates and Implementations for Fee-For-Service
by CHRISTINA.FAULKNER on 06/20/2023
On July 27, 2023, HHSC will implement updates for Cytokine and CAM Antagonists, Pulmonary Hypertension Agents, and Topical Immunomodulators clinical prior authorizations. Additionally, HHSC will revise the Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis prior authorization criteria. The implementation will include the following updates: • Cytokine and CAM Antagonists: o Adding the prior authorization criteria for Sotyktu as approved by the Drug Utilization Review (DUR) Board in April 2023 o Adding Amjevita (a Humira biosimilar product) to the Humira and Biosimilar to the Drugs Requiring Prior Authorization table • Pulmonary Hypertension Agents: o Adding epoprostenol and Orenitam ER to the list of drugs requiring prior authorization. • Topical Immunomodulators: o Adding a check for the application site for Elidel and Protopic 0.3% approval if applied to thin skinned area such as the eyelids. o Updating the approval timeframe for Opzelura to 180 days As a reminder, HHSC will implement Qulipta in the CGRP Antagonists, Prophylaxis prior authorization on June 27. For the latest version of the criteria guide, please visit the following link: These clinical prior authorizations are optional for MCOs. The Pharmacy Clinical Prior Authorization Assistance Chart chart shows which clinical prior authorizations each MCO uses and whether the MCO uses all or some of the steps in the prior authorization evaluation process. This chart is updated quarterly. Providers can refer to the MCO Resources page at for links to each MCO’s list of clinical prior authorizations. To learn more, visit
Semi-annual Medicaid Preferred Drug List Update Coming July 27
by CHRISTINA.FAULKNER on 06/15/2023
Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on July 27. HHSC made the PDL changes based on recommendations made at the January and April 2023 Texas Drug Utilization Review Board meetings. To learn more, visit
Removal of Quantity Limits for Hepatitis C Medications, Including Mavyret Preferred Hepatitis C Treatment
by TALESHIA.CORE on 05/31/2023
On May 25, 2023, HHSC changed the quantity limit on direct-acting antiviral drugs for treating Hepatitis C. This change applies to all Medicaid clients in managed care and fee-for-service. To learn more, visit
Clinical Prior Authorization Criteria for Calcitonin Gene-Related Peptide Receptor Antagonists Effective April 4
by CHRISTINA.FAULKNER on 03/23/2023
On April 4, 2023, HHSC will implement clinical prior authorization criteria for the treatment of calcitonin gene-related peptide receptor (CGRP) antagonists for Medicaid fee-for-service clients. The prior authorization criteria relate to Nurtec orally disintegrating tablets (ODT) and Ubrelvy, which are approved for treating acute migraines. This prior authorization is optional for MCOs. To learn more, visit
HHSC To Revise Livmarli Criteria On May 30
by CHRISTINA.FAULKNER on 04/07/2023
On May 30. 2023, HHSC will update the Livmarli criteria, part of the Cholestatic Pruritis prior authorization, to allow coverage for pediatric patients three months and older. Originally, Livmarli was approved for pediatric patients aged one and older. The Cholestatic Pruritis prior authorization is optional for MCOs. To learn more, visit
Hereditary Angioedema Agents Clinical Prior Authorization Effective for Medicaid Fee-for-Service on April 11
by CHRISTINA.FAULKNER on 03/30/2023
On April 11, 2023, HHSC will implement the Hereditary Angioedema (HAE) Agents (PDF) clinical prior authorization for clients who are enrolled in Medicaid fee-for-service. This clinical prior authorization is optional for Medicaid managed care organizations (MCOs). To learn more, visit
Enzymes Clinical Prior Authorization Effective for Medicaid Fee-for-Service on April 18
by CHRISTINA.FAULKNER on 03/30/2023
On April 18, 2023, HHSC will implement the enzymes clinical prior authorization for clients who are enrolled in Medicaid fee-for-service. This clinical prior authorization is optional for Medicaid managed care organizations (MCOs). To learn more, visit
Implementation of Inhaled Antibiotics Clinical Prior Authorization for Medicaid Fee-For-Service Set for May 2
by CHRISTINA.FAULKNER on 03/23/2023
On May 2, 2023, HHSC will implement the inhaled antibiotics clinical prior authorization for clients enrolled in Medicaid fee-for-service. This prior authorization is optional for MCOs. To learn more, visit
Revisions To Antimigraine Agents (Triptans) Clinical Prior Authorization Criteria Scheduled for April 4
by CHRISTINA.FAULKNER on 03/23/2023
On April 4, 2023, HHSC will revise the clinical prior authorization criteria for antimigraine agents (triptans). This revision will add a step to check for the maximum dose per 30 days of therapy as stated in the products' package inserts for established drug safety dosing. This prior authorization is optional for MCOs. To learn more, and see a list of affected drugs, visit
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