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 Extracts	New prior authorization criteria
Ragwitek (short ragweed pollen allergen extract) Sublingual tablet	Allergen Extracts	New prior authorization criteria
Zavzpret (zavegepant) 10 mg nasal spray	Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment)	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 Agents	New prior authorization criteria
Reblozyl (luspatercept-aamt) 25 and 75 mg vials	Erythropoiesis-Stimulating Agents	New prior authorization criteria
Tyrvaya (varenicline solution) 0.03 mg nasal spray	Immunomodulator Agents for Dry Eye	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) Inhibitors	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