Provider Alert! Updated Clinical Prior Authorizations Criteria Guides

Provider Alert!

Provider Alert! Updated Clinical Prior Authorizations Criteria Guides

Date: September 8, 2023

Attention: All Providers

Effective Date: July 31, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that the Texas Health and Human Services (HHSC) updated multiple clinical prior authorization criteria guides effective July 31, 2023.

How this impacts providers: HHSC updated the following clinical prior authorization criteria guides with the noted changes:

Anxiolytics/Sedatives/Hypnotics (ASH)

  • Ramelteon
    • Corrected step 4 in the Ramelteon criteria logic and diagram.
  • Diazepam
    • Added GCNs for diazepam (45092, 14210) to the prior authorization table
  • Cytokine and CAM Antagonists
    • Amjevita
      • Added generic code numbers (GCNs) for Amjevita (42639, 42637, 42592, 54007)
      • Updated Humira criteria logic and logic diagram to include Amjevita
      • Added diagnosis of Crohn’s disease in adults to Rinvoq
      • Added diagnosis of uveitis for Amjevita
      • Corrected criteria logic for diagnosis of ulcerative colitis for Amjevita.

Multiple Sclerosis

  • Aubagio
    • Added GCNs for teriflunomide (33259, 33262) to drug table

Omega-3 Fatty Acids

  • Vascepa (icosapent ethyl) 500 mg
    • Added GCNs for Icosapent Ethyl (33238, 42365)

Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors

  • Austedo (Deutetrabenazine)
    • Added GCNs for Austedo XR (53736, 53737, 53738) to drug table

Next steps for providers: Prescribers should share this communication and update with their staff. It is important for providers to be aware of the noted and updated changed above regarding HHSC Updated Clinical Prior Authorization criteria guides.


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

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