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 criteriaopen_in_new.

Medications	Clinical criteria guidelines	Clinical criteria updates
Kalydeco (ivacaftor) 13.4, 25, 50 and 75 mg granules packets 150 mg tablet	Cystic Fibrosis Agentsopen_in_new	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 Agentsopen_in_new	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 Antagonistsopen_in_new	Added diagnosis of polymyalgia rheumatica
Rinvoq (upadacitinib) 15, 30 and 45 mg ER tablets	Cytokine and CAM Antagonistsopen_in_new	Added diagnosis of Crohn’s disease in adults
Vowst capsule	Fecal Microbiota Transplantation (FMT) Agentsopen_in_new	New prior authorization criteria
Linzess (linaclotide) 72, 145 and 290 mcg capsules	GI Motility Agentsopen_in_new	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 Agonistsopen_in_new	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 Acidsopen_in_new	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 Agentsopen_in_new	Updated age to 10 years and older for criteria logic and diagram
Veozah (fezolinetant) 45 mg tablet	Veozah (Fezolinetant)open_in_new	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) Inhibitorsopen_in_new	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.

Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.open_in_new For additional contact information, visit our Contact us page.

PCA-1- 23-03804-Clinical-NN_11272023