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

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PCA-1- 23-03804-Clinical-NN_11272023

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