February 01, 2024

Texas: Prior authorization updates for certain medications

Effective March 1, 2024, we’ll make the following changes for UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR Kids and STAR+PLUS plans:

New prior authorization requirements for Grastek®, Ragwitek®, Mircera® and Reblozyl®
Updates to our clinical criteria for Zavzpret™, Tyrvaya® and Austedo®/Austedo® XR

Medications	Clinical criteria guidelines	Clinical criteria updates
Grastek (Timothy grass pollen allergen extract) 2800 BAU sublingual tablet	Allergen Extractsopen_in_new	New prior authorization criteria
Ragwitek (short ragweed pollen allergen extract) Sublingual tablet	Allergen Extractsopen_in_new	New prior authorization criteria
Zavzpret (zavegepant) 10 mg nasal spray	Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment)open_in_new	New prior authorization criteria Added check for concurrent therapy with a prophylactic agent Updated check for concurrent use of contraindicated drugs
Mircera (methoxy polyethylene glycol-epoetin beta) 30, 50, 75, 100, 150 or 200 mcg in 0.3 ml syringe	Erythropoiesis-Stimulating Agentsopen_in_new	New prior authorization criteria
Reblozyl (luspatercept-aamt) 25 and 75 mg vials	Erythropoiesis-Stimulating Agentsopen_in_new	New prior authorization criteria
Tyrvaya (varenicline solution) 0.03 mg nasal spray	Immunomodulator Agents for Dry Eyeopen_in_new	New prior authorization criteria
Austedo (deutetrabenazine) 6, 9 and 12 mg tablets Austedo XR 6, 12 or 24 mg tablets Titration Kit (Week 1-4)	Vesicular Monoamine Transporter 2 (VMAT2) Inhibitorsopen_in_new	Added diagnosis of tardive dyskinesia Added check for dopamine blocking therapy for tardive dyskinesia diagnosis

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PCA-1-23-04204-Clinical-NN_01082024