Provider Alert! Medicaid Preferred Drug List and Formulary Changes

Provider Alert!

Provider Alert! Medicaid Preferred Drug List and Formulary Changes

Date: July 21, 2023

Attention: All Providers

Effective Date: July 27, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective July 27, 2023, select medication(s) moved from “preferred” to “non-preferred” status. A summary of the changes is included below.


Changes with biggest impact to Texas Children Health Plan members and providers:

The drugs listed below were either not previously reviewed (NR) and became non-preferred (NPD) or previously considered a preferred agent (PDL) but now have changed status to non-preferred.

MedicationTypePreferred Alternative
Sumatriptan KitAntimigraine agentsImitrex Kit [B] *
Gvoke syringe [B]Glucagon agentsGvoke pen [B], Baqsimi [B], Glucagon [G]
Zegalogue  [B]Glucagon agentsGvoke pen [B] , Baqsimi  [B] , Glucagon [G]
Ryaltris  [B]Intranasal Rhinitis AgentsCombination preferred antihistamine/corticosteroid therapy (e.g., azelastine & fluticasone)^
TetrabenazineMovement disordersIngrezza [B] *, Xenazine [B]  *, Austedo [B] *
Tadliq suspension [B]PAH agentsAdcirca oral tablets [B] ^
Dyanavel XR tablet [B]Stimulants and related agentsDyanavel XR suspension [B] *
Xelstrym [B]Stimulants and related agentsDextroamphetamine IR tablets [G]
Quillichew ERStimulants and related agentsCotempla XR-ODT [B] *
Entadfi  [B]BPH treatmentsFinasteride [G] ^
Fylnetra [B]Colony Stimulating factorsNyvepria [B]
Skyrizi On-Body  [B]Cytokine and Cam AntagonistsEnbrel [B]^ Humira [B]^
Sotyktu [B]Cytokine and Cam AntagonistsOtezla [B]^
Pradaxa pellet pack (oral)  [B]AnticoagulantPradaxa [B]
Venlafaxine Besylate ER (ORAL)AntidepressantVenlafaxine ER capsules (oral) [G]
Valganciclovir tablet (ORAL) [G]AntiviralValcyte tablet [B]
Amjevita Autoinjector HC (SQ)  [B]TNF inhibitorHumira [B] *
Amjevita Autoinjector LC (SQ)  [B]TNF inhibitorHumira [B] *
Amjevita Syringe (SQ)  [B]TNF inhibitorHumira [B] *
Firazyr (SQ)  [B]HAE TreatmentsIcatibant *
Tezspire Pen (SQ)Anti-AsthmaticXolair [B] *
Protopic (TOPICAL)  [B]Immunomodulator for atopic dermatitisTacrolimus [G]
Noxafil Suspdr PKT (ORAL)AntifungalNoxafil (posaconazole) tablet [B]
Rolvedon Syringe (SQ)  [B]Colony Stimulating FactorGranix [B], Neupogen [B], Nyvepria [B] ^
Stimufend Syringe (SQ)  [B]Colony Stimulating FactorNyvepria [B]
BasaglarTempo Pen (SQ)  [B]AntidiabeticLantus Solostar 100 unit/ML [B]
Humalog Tempo Pen (SQ)  [B]AntidiabeticHumalog Kwikpen [B]
Lyumjev Tempo Pen (SQ)  [B]AntidiabeticHumalog Kwikpen [B]

*In addition to PDL, these medications also have a clinical prior authorization requirement.

^This is a suggested preferred alternative. Please discuss these options with your provider to determine therapy.

[B] Signals the medication is brand name.

[G] Signals the medication is generic.

How this impacts providers: Preferred and non-preferred medications may continue to require clinical prior authorizations. In addition to any clinical prior authorization requirements, non-preferred medications will also require a “step therapy prior authorization.” Non-preferred drugs on the formulary require prior approval and are only approved when there is clinical justification as to why the patient cannot use the preferred drug, including failure/side effects or contraindications to the preferred agents. This means that members must have attempted and failed at least one preferred medication before obtaining a non-preferred medication.

The preferred drug list (PDL) can be found on the VDP website. Medicaid managed care plans are required to follow the PDL.

Next steps for providers: Preferred drugs are medications recommended by the Texas Drug Utilization Review Board for their efficaciousness, clinical significance, cost effectiveness, and safety. TCHP encourages providers to initiate a preferred medication to members new to therapy. When possible, TCHP also encourages switching existing members to a preferred agent.

If you have any questions, please email TCHP Pharmacy Department at: For access to all provider alerts,log into: or

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