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December 14, 2023

Texas: Prior authorization updates for certain medications

Effective Jan. 15, 2024, we’ll make the following changes for UnitedHealthcare Community Plan of Texas STAR, STAR Kids and STAR+PLUS plans:

  • New prior authorization requirements for Vowst™ and Veozah™
  • Updates to our clinical criteria for Austedo®, Austedo XR, icosapent ethyl, Kalydeco®, Kevzara®, Linzess®, Lovaza®, Ozempic®, Rinvoq®, Synjardy®, Synjardy XR, Trikafta®, Trulicity®, Vascepa®, Victoza® and Xenazine®

These changes align with new Texas Health and Human Services Commission criteria.

Medications Clinical criteria guidelines Clinical criteria updates
Kalydeco (ivacaftor)
  • 13.4, 25, 50 and 75 mg granules packets
  • 150 mg tablet
 Cystic Fibrosis Agents Removed age check

Trikafta (elexcaftor/tezacaftor/ivacaftor)

  • 100-50-75 mg/75 mg and 80-40-60 mg/59.5 mg packets
  • 50-25-37.5 mg/75 mg and 100-50-75 mg/150 mg tablets
 Cystic Fibrosis Agents Updated age to 2 years and older

Kevzara (sarilumab)

  • 150 mg/1.14 ml and 200 mg/1.14 ml pens
  • 150 mg/1.14 ml and 200 mg/1.14 ml syringes
 Cytokine and CAM Antagonists Added diagnosis of polymyalgia rheumatica

Rinvoq (upadacitinib)
15, 30 and 45 mg ER tablets

 Cytokine and CAM Antagonists Added diagnosis of Crohn’s disease in adults
Vowst capsule Fecal Microbiota Transplantation (FMT) Agents New prior authorization criteria
Linzess (linaclotide)
72, 145 and 290 mcg capsules		 GI Motility Agents Updated criteria to include patients aged 6 to 17 years old with a diagnosis of functional constipation

Ozempic (semaglutide)
0.25-0.5 mg/dose (3 ml), 4 mg/dose (3 ml) and 8 mg/dose (3 ml) pens

Trulicity (dulaglutide)
0.75 mg/0.5 ml, 1.5 mg/0.5 ml, 3 mg/0.5 ml and 4.5 mg/0.5 ml pens

Victoza (liraglutide)
18 mg/3 ml pen

 Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

For all: Added check for atherosclerotic cardiovascular disease (ASCVD), heart failure (HF) and chronic kidney disease (CKD) without prior oral antidiabetic therapy

For Trulicity only: Updated age to 10 years and older

Icosapent ethyl

  • 500 mg capsule
  • 0.5 and 1 g capsules

Vascepa (icosapent ethyl)
1 g capsule

Lovaza (omega-3 acid ethyl esters)
1 g capsule

 Omega-3 Fatty Acids Updated maximum dosing to ≤ 4 grams per day

Jardiance (empagliflozin)
10 and 25 mg tablets

Synjardy (empagliflozin/metformin)
5-1000, 12.5-500 and 12.5-1000 mg tablets

Synjardy XR (empagliflozin/metformin)
5-1000, 10-1000, 12.5-1000 and 25-1000 mg tablets

 SGLT2 Inhibitor Agents Updated age to 10 years and older for criteria logic and diagram
Veozah (fezolinetant)
45 mg tablet		 Veozah (Fezolinetant) New prior authorization criteria

Austedo (deutetrabenazine)
6, 9 and 12 mg tablets

Austedo XR (deutetrabenazine)
6, 12 and 24 mg tablets

Tetrabenazine
12.5 and 25 mg tablets

Xenazine (tetrabenazine)
12.5 and 25 mg tablets

 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors

For all: Added check for dopamine blocking therapy for tardive dyskinesia diagnosis

For Austedo and Austedo XR only: Added diagnosis of tardive dyskinesia

Questions? We're here to help

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PCA-1- 23-03804-Clinical-NN_11272023

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