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 July 19, 2021)*
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 (Pending Implementation) (Revised July 1, 2021)*
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 July 19, 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 July 19, 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 June 1, 2021)*
Growth Hormone Agents (Revised June 8, 2021)*
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 (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 June 18, 2021)*
Lyrica (Pending Implementation) (Revised June 26, 2020)*
Makena (Revised May 14, 2019)*
Monoclonal Antibodies for Asthma (Pending Implementation) (Revised June 8, 2021)*
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 July 19, 2021)*
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 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 19, 2021)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised June 18, 2021)*
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 July 19, 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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Change in Texas Pharmacy Prior Authorization Call Center Fax Number
by CHRISTINA.FAULKNER on 07/16/2021
The Texas Pharmacy Prior Authorization Call Center fax number (1-866-617-8864) is currently experiencing technical issues. Beginning immediately, prescribing providers should fax prior authorization requests to 1-844-419-6543 until further notice. Providers can only make prior authorization requests by phone or online. To learn more, visit
Changes to Hepatitis C Prior Authorization Criteria
by CHRISTINA.FAULKNER on 06/29/2021
Beginning September 1, 2021, Medicaid will expand coverage of the Hepatitis C virus clinical prior authorization criteria to include all metavir fibrosis scores. To learn more, visit
Atypical Respiratory Syncytial Virus (RSV) Season Advisory
by CHRISTINA.FAULKNER on 07/21/2021
RSV infections in Texas typically occur during the fall and winter months. HHSC observed very little activity during the traditional 2020-21 season, likely due to the adoption of public health measures to reduce the spread of COVID-19. This period of unusually low activity has been followed during the late spring and summer months by an unusual resurgence of RSV activity. In response, on June 21, 2021, HHSC began opening DSHS regions for RSV prophylaxis with Palivizumab (Synagis) for clients currently meeting clinical criteria. On July 23, 2021, HHSC will open all DSHS regions and providers may start monthly Palivizumab (Synagis) injections for RSV prophylaxis for clients who meet clinical criteria. This reopening is considered the start of a new RSV season, separate from the regular 2020-21 RSV season. At this time, clients who meet the prior authorization criteria qualify for up to 5 monthly shots of Palivizumab (Synagis). We will announce further guidance as new developments arise. To learn more, visit
Semi-annual Medicaid Preferred Drug List Update Coming July 29
by CHRISTINA.FAULKNER on 06/18/2021
Texas Medicaid will perform the semi-annual update of the Medicaid preferred drug list on July 29. HHSC made the PDL changes based on recommendations made at the January and April 2021 Texas Drug Utilization Review Board meetings. Drug list recommendations and decisions from those meetings are available. To learn more, visit
Nucala Clinical Prior Authorization Update Begins July 12
by CHRISTINA.FAULKNER on 06/18/2021
HHSC will revise the Nucala clinical prior authorization criteria section in the Monoclonal Antibody Agents for Asthma clinical prior authorization following the US Food and Drug Administration approved indications. Nucala is a monoclonal antibody prescribed as maintenance therapy for patients 6 years and older with severe eosinophilic asthma. However, the autoinjector and prefilled syringe products are only FDA-approved for at-home use for adults and adolescents age 12 and older. This clinical prior authorization is optional for MCOs. To learn more, visit
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
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
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
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
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
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