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TX
WISeR pilot

Texas Prior Authorization Requirements

Medicaid MCO • STARMedicare AdvantageDual-EligibleMedicare TraditionalPart DMedicaid FFS • STARCommercial (employer / fully-insured)Commercial — Marketplace QHP

PA required

65%

237 verified rules

Verified May 22, 2026

Service category PA

All programs combined
Specialty Drugs
5/6Conditional
Durable Medical Equipment
5/6Conditional
Inpatient Hospital
4/6Conditional
Outpatient Surgery
4/6Conditional
Skilled Nursing Facility
4/6Conditional
Mental Health — Inpatient
4/6Conditional
Home Health
4/6Conditional
Ambulance Transport
3/6Conditional
Occupational Therapy
3/6Conditional
Physical Therapy
3/6Conditional
Speech Therapy
3/6Conditional
Diagnostic Imaging
3/6Conditional
Substance Use Treatment
3/6Conditional
advanced_imaging
3/6Conditional
Laboratory
0/6No PA

Drug class PA

Part D federal protections flagged
Specialty Biologics
10/11Conditional
Oral OncologyFed. Protected
8/11Conditional
Rare Disease / Orphan
7/8Conditional
Hepatitis C
7/8Conditional
Immunosuppressants
6/9Conditional
GLP-1 (Weight Loss)
5/11Conditional
Controlled — Schedule III–V
5/6Conditional
Biosimilars
5/6Conditional
Controlled — Schedule II
5/6Conditional
Brand (Generic Available)
5/6Conditional
ADHD Stimulants
5/6Conditional
Diabetes — Insulin
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Brand (No Generic)
5/6Conditional
Specialty Non-Biologic
5/6Conditional
glp1_diabetes
4/4Full PA
Antipsychotics
4/7Conditional
HIV Antiretrovirals
3/6Conditional
Antidepressants
3/6Conditional
Opioid Treatment (MOUD)
0/6No PA
Compounded Medications
0/6No PA

PA type breakdown

Conditional
83
Full PA
49
clinical_criteria
21

Federal protected classes requiring PA

Oral OncologyPA required
AntidepressantsPA required
ImmunosuppressantsPA required
AntipsychoticsPA required
HIV AntiretroviralsPA required

State flags

Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)

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