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HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021PREFERRED DRUG LIST PUBLICATION LOGThe PDL is published biannually (January, July). Recent changes to the PDL status are highlighted:July 29, 2021:PublishedACNE AGENTS, ORALPreferred AgentsAMNESTEEM (isotretinoin)CLARAVIS (isotretinoin) isotretinoinMYORISAN (isotretinoin)ZENATANE (isotretinoin)Non-Preferred AgentsABSORICA (isotretinoin)ABSORICA LD (isotretinoin)PA CriteriaClient must meet at least one of thelisted PA criteria Treatment failure withpreferred drugs within anysubclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20211 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ACNE AGENTS, TOPICALPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one of thelisted PA criteriaAntibioticsclindamycin gelclindamycin pledgetsclindamycin solutionerythromycin gel, solutionAMZEEQ (minocycline)CLEOCIN-T (clindamycin) clindamycin foamclindamycin gel AG (Clindagel)clindamycin lotionerythromycin medicated swab Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction to preferreddrugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugs inthe class: Topical Acne AgentsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20212 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ACNE AGENTS, TOPICALcontinuedPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one of thelisted PA criteriaBenzoyl Peroxidebenzoyl peroxide gel (Rx)benzoyl peroxide lotion (OTC)benzoyl peroxide washBENZEFOAM FOAM OTC (topical)benzoyl peroxide cleanserbenzoyl peroxide creambenzoyl peroxide foambenzoyl peroxide gelbenzoyl peroxide kitbenzoyl peroxide towelette Treatment failure withpreferred drugs withinany subclassContraindication to preferreddrugsAllergic reaction to preferreddrugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugs inthe class: Topical Acne AgentsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20213 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ACNE AGENTS, TOPICALcontinuedPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one of thelisted PA criteriaRetinoidstretinoin cream (Avita, Retin-A)tretinoin gelAKLIEF (trifarotene)adapaleneALTRENO (tretinoin)ARAZLO (tazarotene)ATRALIN (tretinoin)AVITA (tretinoin)DIFFERIN (adapalene)FABIOR (tazarotene)tazaroteneTAZORAC (tazarotene)tretinoin gel (Atralin)tretinoin microspheres Treatment failure withpreferred drugs withinany subclassContraindication to preferreddrugsAllergic reaction to preferreddrugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugs inthe class: Topical RetinoidsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20214 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ACNE AGENTS, TOPICALcontinuedPreferred Agentsbenzoyl peroxide/clindamycin (Duac)erythromycin/benzoyl peroxideNon-Preferred AgentsPA CriteriaClient must meet at least one of thelisted PA criteriaCombination and Other AgentsACZONE 7.5% (dapsone)AZELEX (azelaic acid)BENZACLIN GEL amide sodium/sulfursulfacetamide/sulfurbenzoyl peroxide yl peroxideZIANA eDUAC (benzoylperoxide/clindamycin)EPIDUO (benzoylperoxide/adapalene)EPIDUO FORTE (benzoyl sulfacetamide sodium Treatment failure withpreferred drugs withinany subclassContraindication to preferreddrugsAllergic reaction to preferreddrugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugs inthe class: Retinoids Topical Acne Agentsperoxide/adapalene)To verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20215 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ALZHEIMER’S AGENTSPreferred AgentsNon-Preferred AgentsCholinesterase Inhibitorsdonepezil 5, 10 mg tablet*donepezil ODT*EXELON (rivastigmine) transdermalARICEPT (donepezil)*donepezil 23 mg tablet*galantamine*galantamine ERRAZADYNE (galantamine) tablet*RAZADYNE ER (galantamine ER)rivastigmine capsulesrivastigmine transdermalNMDA Receptor Antagonistmemantine tabletsmemantine solutionmemantine tablet dose packNAMENDA (memantine) tabletsNAMENDA XR (memantine)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsFor drugs in a therapeuticclass or subclass with nopreferred option, theprovider must obtain a PDLprior authorizationDose Optimization applies tosome strengths where a “*” isnotedCholinesterase Inhibitor/NMDA Receptor Antagonist CombinationsNAMZARIC (donepezil/memantine)To verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20216 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANALGESICS, NARCOTIC – LONG ACTINGPreferred AgentsBUTRANS (buprenorphine)EMBEDA (morphine/naloxone)fentanyl patch (12.5, 25, 50, 75, 100 mcg)morphine ER (generic MS Contin)tramadol ER (Ultram ER)XTAMPZA ER (oxycodone)Non-Preferred AgentsBELBUCA (buprenorphine)buprenorphine patchDURAGESIC (fentanyl)EXALGO (hydromorphone)fentanyl patch (37.5, 62.5, 87.5mcg)hydromorphone ERHYSINGLA ER (hydrocodone)KADIAN (morphine)methadoneMORPHABOND ER (morphine)morphine ER (generic Avinza,Kadian)MS CONTIN (morphine)NUCYNTA ER (tapentadol)OPANA ER (oxymorphone)oxycodone EROXYCONTIN (oxycodone)oxymorphone ERtramadol ER (generic Conzip, Ryzolt)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsMethadone oral solutionwill be authorized forpatients less than 24months of age.The following Clinical PriorAuthorization applies to all drugsin the class: Morphine MilligramEquivalent Opiate Overutilization Opiate/Benzodiazepine/Muscle RelaxantA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20217 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANALGESICS, NARCOTIC – SHORT ACTING (NON-PARENTERAL)Preferred rofenhydromorphone tabletmorphine tabletsmorphine solutionoxycodone solutionoxycodone rred AgentsACTIQ (fentanyl)APADAZ caffeineDILAUDID (hydromorphone)DSUVIA (sufentanil citrate)fentanyl buccalFENTORA (fentanyl)FIORINAL phone liquidhydromorphone suppositoriesIBUDONE (hydrocodone/ibuprofen)LAZANDA (fentanyl)levorphanolmeperidinemorphine concentrated solutionNALOCET (oxycodone/APAP)NORCO (hydrocodone/APAP)NUCYNTA (tapentadol)OPANA (oxymorphone)oxycodone/APAP ycodone capsuleoxycodone concentrate solutionoxymorphonepentazocine/naloxonePERCOCET (oxycodone/APAP)ROXICODONE (oxycodone)SUBSYS (fentanyl)TYLENOL-CODEINE (codeine/APAP)ULTRACET (tramadol/APAP)ULTRAM (tramadol)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugsin the class: Morphine MilligramEquivalent Opiate Overutilization Opiate/Benzodiazepine/Muscle RelaxantA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20218 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANDROGENIC AGENTS, TOPICALPreferred AgentsANDROGEL (testosterone) pumpNon-Preferred AgentsANDRODERM (testosterone)ANDROGEL (testosterone) packetFORTESTA (testosterone)TESTIM (testosterone)testosterone gelVOGELXO (testosterone)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to alldrugs in the class: Androgenic AgentsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 20219 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATORSPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one ofthe listed PA criteriaAce InhibitorsbenazeprilEPANED ACCUPRIL (quinapril)ALTACE (ramipril)*captoprilmoexeprilperindopril*PRINIVIL (lisinopril)ramipril*QBRELIS (lisinopril) solutiontrandolapril*VASOTEC (enalapril) Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsEpaned will be authorizedfor patients six years ofage and underDose Optimization applies tosome strengths where a “*” isnotedTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202110 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATORScontinuedPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one of thelisted PA criteriaACE Inhibitor/Diuretic alapril/HCTZ)ZESTORETIC(lisinopril/HCTZ) Treatment failure with preferreddrugs within any subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-four advanced,metastatic cancer and associatedconditionsThe following Clinical PriorAuthorization applies to all drugs in theclass: Duplicate TherapyTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202111 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATORScontinuedPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one ofthe listed PA criteriaAngiotensin II Receptor Blockers (ARBs)DIOVAN (valsartan)*irbesartan*losartan*ATACAND (candesartan)*AVAPRO (irbesartan)*BENICAR (olmesartan)*candesartan*COZAAR (losartan)*EDARBI rtan*telmisartan*valsartan* Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugsin the class: Duplicate TherapyDose Optimization applies tosome strengths where a “*” isnotedTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202112 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATORScontinuedPreferred AgentsNon-Preferred Agents ARB/Diuretic CT (candesartan/HCTZ)AVALIDE (irbesartan/HCTZ)BENICAR-HCT (olmesartan/HCTZ)candesartan/HCTZDIOVAN-HCT ne)HYZAAR (losartan/HCTZ)*PA CriteriaClient must meet at least one ofthe listed PA criteriaMICARDIS-HCT (telmisartan/HCTZ)olmesartan/HCTZtelmisartan /HCTZvalsartan/HCTZ Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsFor drugs in a therapeuticclass or subclass with nopreferred option, theprovider must obtain a PDLprior authorizationThe following Clinical PriorAuthorization applies to all drugsin the class: Duplicate TherapyDirect Renin InhibitorsTEKTURNA (aliskerin)Direct Renin Inhibitor/Diuretic CombinationsTEKTURNA HCT (aliskerin/HCTZ)Dose Optimization applies tosome strengths where a “*” isnotedA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202113 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATORScontinuedPreferred AgentsNon-Preferred AgentsPA CriteriaClient must meet at least one ofthe listed PA criteriaARB/Neprilysin Inhibitor CombinationsENTRESTO (valsartan/sacubitril) Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugsin the class: Duplicate TherapyTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202114 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANGIOTENSIN MODULATOR COMBINATIONSPreferred Agentsbenazepril /amlodipinevalsartan/amlodipineNon-Preferred AgentsAZOR (olmesartan/amlodipine)BYVALSON (valsartan/nebivolol)EXFORGE (valsartan/amlodipine)LOTREL pril/verapamilvalsartan/amlodipine/HCTZPA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202115 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTI-ALLERGENS, ORALPreferred AgentsNon-Preferred AgentsORALAIR (Sweet Vernal, Orchard, Perennial Rye, Timothy, & Kentucky BlueGrass mixed pollens allergen extract)PALFORZIA MAINTENANCE SACHET (peanut allergen powder)PALFORZIA TITRATION CAPSULE (peanut allergen powder)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsFor drugs in a therapeuticclass or subclass with nopreferred option, theprovider must obtain a PDLprior authorizationA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202116 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTIBIOTICS, GASTROINTESTINALPreferred AgentsFIRVANQ(vancomycin)metronidazole tabletneomycintinidazoleNon-Preferred AgentsDIFICID (fidaxomicin)FLAGYL (metronidazole)metronidazole capsuleparomomycinTINDAMAX (tinidazole)VANCOCIN (vancomycin)vancomycinXIFAXAN (rifaximin)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202117 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTIBIOTICS, INHALEDPreferred AgentsBETHKIS (tobramycin)CAYSTON (aztreonam)KITABIS PAK (tobramycin)TOBI PODHALER (tobramycin)Non-Preferred AgentsARIKAYCE (amikacin)TOBI (tobramycin) solutiontobramycin solutionPA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugsin the class: Antibiotics, InhaledTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202118 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTIBIOTICS, TOPICALPreferred Agentsbacitracin ointmentmupirocin ointmenttriple antibiotic ointmentneomycin/polymyxin/pramoxineNon-Preferred AgentsCENTANY (mupirocin)gentamicinmupirocin creammupirocin ointment syringeXEPI (ozenoxacin)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsANTIBIOTICS, VAGINALPreferred AgentsCLEOCIN (clindamycin) ovulesCLINDESSE (clindamycin)NUVESSA (metronidazole)Non-Preferred AgentsCLEOCIN (clindamycin) creamclindamycinmetronidazoleSOLOSEC (secnidazole)VANDAZOLE (metronidazole)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202119 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTICOAGULANTSPreferred AgentsELIQUIS (apixaban)enoxaparinPRADAXA (dabigatran)warfarinXARELTO (rivaroxaban)Non-Preferred AgentsARIXTRA (fondaparinux)BEVYXXA (betrixaban)COUMADIN (warfarin)fondaparinuxFRAGMIN (dalteparin)LOVENOX (enoxaparin)SAVAYSA (edoxaban)PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsThe following Clinical PriorAuthorization applies to all drugsin the class: Duplicate TherapyTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202120 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTICONVULSANTSPreferred AgentsNon-Preferred AgentsAPTIOM (eslicarbazine)BANZEL (rufinamide)BRIVIACT (brivaracetam)carbamazepinecarbamazepine ER, XRCARBATROL (carbamazepine)CELONTIN (methsuximide)clobazamclonazepamDEPAKOTE (divalproex sodium)DEPAKOTE ER (divalproex sodium)DIACOMIT (stiripentol)DIASTAT (diazepam)DIASTAT ACUDIAL (diazepam)diazepamDILANTIN (phenytoin)DILANTIN INFATAB (phenytoin)divalproexdivalproex EREPIDIOLEX (cannabidiol)EQUETRO (carbamazepine)ethosuximidefelbamateFELBATOL (felbamate)FINTEPLA (fenfluramine)FYCOMPA (perampanel)GABITRIL (tiagabine)KEPPRA (levetiracetam)KEPPRA XR (levetiracetam)KLONOPIN (clonazepam)LAMICTAL (lamotrigine) tablet, ODTLAMICTAL XR (lamotrigine)lamotrigine tablet, ODTlevetiracetamlevetiracetam XRPA CriteriaClient must meet at least one ofthe listed PA criteria All of the agents in theAnticonvulsants class arepreferredA drug specific priorauthorization applies to drugswith a hyperlinkTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202121 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTICONVULSANTSPreferred AgentscontinuedNon-Preferred AgentsMYSOLINE (primidone)NAYZILAM (midazolam)ONFI (clobazam)oxcarbazepineOXTELLAR XR (oxcarbazepine)PEGANONE (ethotoin)phenobarbitalPHENYTEK (phenytoin)phenytoinprimidoneQUDEXY XR (topiramate)SABRIL (vigabatrin)SPRITAM (levetiracetam)SYMPAZAN (clobazam)TEGRETOL (carbamazepine)TEGRETOL XR (carbamazepine)tiagabineTOPAMAX (topiramate)topiramatetopiramate ERTRILEPTAL (oxcarbazepine)TROKENDI XR (topiramate)valproic acidVALTOCO (diazepam)zonisamidevigabatranVIMPAT (lacosamide)XCOPRI (cenobamate)ZARONTIN (ethosuximide)PA CriteriaClient must meet at least one ofthe listed PA criteria All of the agents in theAnticonvulsants class arepreferredTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202122 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTIDEPRESSANTS, OTHERPreferred Agentsbupropionbupropion SRbupropion XL*mirtazapine*phenelzinetrazodonevenlafaxine ER capsules*venlafaxine IRNon-Preferred AgentsAPLENZIN (bupropion)desvenlafaxine EREFFEXOR XR (venlafaxine)*EMSAM (selegiline)FETZIMA (levomilnacipran)FORFIVO XL (bupropion)KHEDEZLA (desvenlafaxine)MARPLAN (isocarboxazid)NARDIL (phenelzine)nefazodonePRISTIQ (desvenlafaxine)REMERON (mirtazapine)*tranylcypromineTRINTELLIX (vortioxetine)venlafaxine ER tablets*VIIBRYD (vilazodone)WELLBUTRIN SR (bupropion)WELLBUTRIN XL (bupropion)*PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsDose Optimization applies tosome strengths where a “*” isnotedTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202123 of 137
HEALTH AND HUMAN SERVICES COMMISSIONTEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIAEffective July 29, 2021ANTIDEPRESSANTS, SSRISPreferred Agentscitalopram*escitalopram tablets*fluoxetine IRfluvoxamineparoxetine*sertraline*Non-Preferred AgentsBRISDELLE (paroxetine)CELEXA (citalopram)*escitalopram solutionfluoxetine capsule DRfluoxetine 60mg tabletsfluvoxamine ERLEXAPRO (escitalopram)*paroxetine CR*PAXIL (paroxetine)*PAXIL CR (paroxetine)*PROZAC (fluoxetine)ZOLOFT (sertraline)*PA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsDose Optimization applies tosome strengths where a “*” isnotedANTIDEPRESSANTS, TRICYCLICPreferred Agentsamitriptylinedoxepinimipraminenortriptyline capsuleNon-Preferred AgentsamoxapineANAFRANIL (clomipramine)clomipraminedesipramineimipramine pamoatemaprotilinenortriptyline solutionPAMELOR (nortriptyline)protriptylineSURMONTIL (trimipramine)TOFRANIL (imipramine)trimipraminePA CriteriaClient must meet at least one ofthe listed PA criteria Treatment failure withpreferred drugs withinany subclassContraindication topreferred drugsAllergic reaction topreferred drugsTreatment of stage-fouradvanced, metastatic cancerand associated conditionsTo verify formulary coverage for any drugs listed on PDL, Search the Medicaid rchUnless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.Publication date: July 29, 202124 of 1
HEALTH AND HUMAN SERVICES COMMISSION TEXAS MEDICAID PREFERRED DRUG LIST (PDL) and PRIOR AUTHORIZATION (PA) CRITERIA Effective July 29, 2021 To verify formulary coverage for any drugs listed on PDL, Search the Medicaid Formulary:
