Medicaid/CHIP Prior Authorization

Medicaid/CHIP Prior Authorization

Prior authorization is the review of the medical necessity and appropriateness of selected health services before they are provided. The prior authorization list is reviewed and revised periodically to ensure only those services that are medical management issues are subject to review by the health plan and approved before the services are eligible for reimbursement.

Medicaid providers must submit the Texas Standard Prior Authorization request form with all prior authorization requests.

Formulary

2017 Pharmacy Formulary

Pregnancy

Pregnancy Notification Form (PDF)

Pharmacy Prior Authorization Request Forms

In an effort to ensure safety and optimal care for our members, we have implemented 5 years of age or older as the age restriction for all CII Stimulants with the exception of the following agents: AMPHETAMINE SALTS IR, PROCENTRA, DEXTROAMPHETAMINE, METHYLPHENIDATE SOLUTION and ZENZEDI. The five drugs listed have an age restriction of 3 years of age or older.

CHIP

Abstral (PDF)
Accolate - Zafirlukast (PDF)
Actiq (PDF)
ADD-ADHD ER Formulations (PDF)
Alinia Suspension (updated 09/01/2016) (PDF)
Alprazolam (updated 06/30/2017) (PDF)
Amitiza (PDF)
Antiemetics (updated 3/22/2017) (PDF)
Antipsychotics (updated 2/08/2017) (PDF)
Anxiolytics-Clonazepam, Diazepam (updated 06/30/2017) (PDF)
Anxiolytics-Chlordiaz, Meprobam, Oxaz (updated 06/30/2017)
Aranesp (PDF)
Buspirone (updated 06/30/2017)
Butabarbital (updated 06/30/2017)
Clorazepate (updated 06/30/2017)

Cyclobenzaprine (PDF)
Duragesic (PDF)
Emflaza (PDF)
Epogen (PDF)
Fentora (PDF)
Flurazepam (updated 06/30/17) (PDF)
Forteo (updated 06/30/17) (PDF)
Growth Hormone (updated 2/26/2015) (PDF)
Ilaris (PDF)
Kalydeco (PDF)
Ketorolac Nasal Injection (updated 09/29/2016) (PDF)
Ketorolac Tablets (updated 09/29/2016) (PDF)
Lazanda (PDF)
Linzess (PDF)
Lorazepam (updated 6/30/17) (PDF)
Lotronex (PDF)
Movantik (PDF)
Nuedexta (PDF)
Opioid-Benzodiazepine-Muscle Relaxant Combinations (PDF)
Orkambi (updated 3/24/2016) (PDF)
Plavix (updated 3/21/2017) (PDF)
Praluent (updated ) (PDF)
Procrit (PDF)
Ramelteon (updated 6/30/17 ) (PDF)
Relistor (PDF)
Repatha (upated ) (PDF)
Sedative_Hypnotics (upated 6/30/17 ) (PDF)
Singulair (PDF)
Suboxone (updated 02/15/2017) (PDF)
Subsys (PDF)
Subutex (updated 02/15/2017) (PDF)
Xenical (PDF)
Zyflo (PDF)
H.P. Acthar Gel (update 4/18/2016) (PDF)

Medicaid

Abstral (PDF)
Accolate - Zafirlukast (PDF)
Actiq (PDF)
Actiq 200mcg (updated 2/26/2015) (PDF)
Actiq excluding 200mcg (updated 2/26/2015) (PDF)
Actemra (updated 2/26/2015) (PDF)
Actos - Actoplus Met - Actoplus Met XR (updated 2/26/2015) (PDF)
ADD-ADHD ER Formulations (PDF)
ADHD IR (updated 2/26/2015) (PDF)
ADHD Non-Stimulant (updated 2/26/15) (PDF)
Amitiza (PDF)
Aldara (updated 2/26/2015) (PDF)
Alinia Suspension (updated 09/1/2016) (PDF)
Aliskiren - Containing Agents 150mg (updated 2/26/2015) (PDF)
Aliskiren - Containing Agents 300mg (updated 2/26/2015) (PDF)
Altabax (updated 2/26/2015) (PDF)
Amitiza (updated 2/26/2015) (PDF)
Amrix, Flexeril (updated 2/26/2015) (PDF)
Antiemetics (updated 3/22/2017) (PDF)
Antipsychotics (updated 2/08/2017) (PDF)
Anxiolytics - Alprazolam (updated 09/1/2015) (PDF)
Anxiolytics - Chlordiaz, Meprobam, Oxaz (PDF)
Anxiolytics - Clonazepam, Diazepam (updated 6/30/2017) (PDF)
Anxiolytics - Lorazepam (updated 2/26/2015) (PDF)
Aranesp (PDF)
Avandia-Avandamet-Avandaryl (updated 2/26/2015) (PDF)
Buspirone (updated 06/30/2017) (PDF)
Butabarbital (updated 06/30/2017) (PDF)
Byetta (updated 2/26/2015) (PDF)
Cerezyme (updated 6/30/17) (PDF)
Cimzia (PDF)
Cinrzyze-Firazyr (PDF)
Clorazepate (updated 06/30/17) (PDF)
Combo Alprazolam, Carisoprodol, Hydrocodone (updated 2/26/2015) (PDF)
Copaxone (PDF)
Cox-II Inhibitors (updated 2/26/2015) (PDF)
Cyclobenzaprine (PDF)
DDAVP Injection (updated 2/26/2015) (PDF)
DDAVP Tablets (updated 2/26/2015) (PDF)
Diovan-Ramipril (updated 2/26/2015) (PDF)
Duragesic (PDF)
Duragesic (updated 2/26/2015) (PDF)
Duetact (updated 2/26/2015) (PDF)
Elelyso (updated 2/26/2015) (PDF)
Elidel and Protopic 0.03% (updated 2/26/2015) (PDF)
Emflaza (PDF)
Epogen (PDF)
Eucrisa (PDF)
Fentora (PDF)
Flurazepam (updated 06/30/17) (PDF)
Forteo (PDF)
Fosrenol (updated 8/2016) (PDF)
Grastek (updated 01/21/2016) (PDF)
Hepatitis C Agents (PDF)
H.P. Acthar Gel (updated 4/18/2016) (PDF)
Ilaris (PDF)
Increlex (updated 2/26/2015) (PDF)
Injectable PAH (PDF)
Januvia 25mg (updated 2/26/2015) (PDF)
Januvia 50mg (updated 2/26/2015) (PDF)
Januvia 100mg (updated 2/26/2015) (PDF)
Ketorolac Nasal Injection (updated 09/26/2016) (PDF)
Ketorolac Tablets (updated 09/26/2016) (PDF)
Kalydeco (PDF)
Kineret (PDF)
Lazanda (PDF)
Lidoderm Transdermal Patch (updated 6/22/2015) (PDF)
Linzess (PDF)
Lorazepam (updated 06/30/17) (PDF)
Lotronex (PDF)
Lovaza (updated 2/26/2015) (PDF)
Makena (updated 06/22/2015) (PDF)
Movantik (PDF)
Muscle Relaxants Benzodiazepine Combinations (PDF)
Neurontin (updated 2/26/2015) (PDF)
Nuedexta (PDF)
Opiate Overutilization (updated 2/26/2015) (PDF)
Opioid-Benzodiazepine Combinations (PDF)
Opioid-Benzodiazepine-Muscle Relaxant Combinations (PDF)
Oralair (updated 01/21/2016) (PDF)
Orencia (PDF)
Orkambi (PDF)
Oxycontin 10mg - 40mg (updated 2/26/2015) (PDF)
Oxycontin 60mg & 80mg (updated 2/26/2015) (PDF)
Phenergan (updated 2/26/2015) (PDF)
Phosphate Binder (updated 2/26/2015) (PDF)
Plavix (updated 3/21/2017) (PDF)
Praluent (updated 02/13/2017) (PDF)
Procrit (PDF)
Propylthiouracil (updated 2/26/2015) (PDF)
Protopic 0.1% (updated 2/26/2015) (PDF)
Provigil (updated 2/26/2015) (PDF)
Ramelteon (PDF)
Ragwitek (updated 01/21/2016) (PDF)
Ranexa (updated 2/26/2015) (PDF)
Relistor (PDF)
Repatha (updated 02/13/2017) (PDF)
Revatio (updated 10/20/2015) (PDF)
Savella (updated 01/11/2016) (PDF)
Sedative_Hypnotics (updated 06/30/2017) (PDF)
Serostim (updated 2/26/2015) (PDF)
Simponi (PDF)
Singulair (PDF)
Soma (updated 2/26/2015) (PDF)
Soma Compound (updated 2/26/2015) (PDF)
Stelara (PDF)
Suboxone (updated 01/5/2017) (PDF)
Subsys (PDF)
Subutex (updated 01/5/2017) (PDF)
Symlin (updated 2/26/2015) (PDF)
Synagis (updated 10/8/2015) (PDF)
Victoza (updated 2/26/2015) (PDF)
Vpriv (updated 2/26/2015) (PDF)
Xeljanz (PDF)
Xenical (PDF)
Xifaxan 200mg (updated 2/26/2015) (PDF)
Xifaxan 550mg (updated 12/15/2015) (PDF)
Xyrem (updated 2/26/2015) (PDF)
Zavesca (updated 2/26/2015) (PDF)
Zorbtive (updated 2/26/2015) (PDF)
Zyclara (updated 2/26/2015) (PDF)
Zyflo (PDF)

Standard PA Forms and Addendums

Standard PA Form (PDF)
Growth Hormone Addendum (PDF)
Hepatitis C Addendum - Initial (PDF)
Increlex Addendum (PDF)
Kalydeco Addendum (PDF)
Makena Addendum (PDF)
Oxycontin Addendum (PDF)
Phosphate Binders Addendum (PDF)
Xyrem Addendum (PDF)