Clinical Criteria
ADD/ADHD (Pending Implementation) (Revised July 11, 2022)*
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 July 25, 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 October 22, 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 January 24, 2022)*
CGRP Antagonists, Prophylaxis (Revised November 8, 2022)*
Cholestatic Pruritis Agents (Pending Implementation) (Revised October 20, 2022)*
CNS Stimulants (Pending Implementation) (Revised October 20, 2022)*
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 September 19, 2022)*
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 July 18, 2022)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 28, 2022)*
Gaucher's Disease Agents (Pending Implementation) (Revised July 15, 2019)*
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 July 24, 2020)*
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 July 15, 2019)*
Lidocaine Patches (Pending Implementation) (Revised November 7, 2019)*
Lovaza (Pending Implementation) (Revised July 5, 2022)*
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 October 28, 2022)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
Monoclonal Antibody Agents - Dupixent (Revised March 10, 2022)*
Multiple Sclerosis Agents (Pending Implementation) (Revised May 24, 2022)*
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)*
Opiate Overutilization (Revised October 31, 2022)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised January 30, 2020)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised July 24, 2020)*
Oxycontin / Narcotic Analgesic (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 February 13, 2020)*
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 October 19, 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)*
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Announcements
October 2022 Drug Utilization Review Board Meeting Summary
by TALESHIA.CORE on 11/01/2022
The Texas Drug Utilization Review Board met Friday, October 21, to make recommendations about clinical prior authorizations and drugs on the Texas Medicaid Preferred Drug List. Available online is a recording of this meeting’s webcast, a report of this quarter’s clinical prior authorization and PDL recommendations, and approved minutes from the Friday, July 22, meeting. 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.
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 txvendordrug.com/about/news.