Texas Standard Prior Authorization Form and Addendum Instructions

Requests for pharmacy prior authorization may be submitted via fax or mail using the Texas Standard Prior Authorization Form beginning September 1, 2015.  Prescribing providers may continue, and are encouraged, to request prior authorization for fee-for-service Medicaid patients by calling the Texas Prior Authorization Call Center. Please visit PAxpress for forms and addendums for clinical prior authorization requests. The below forms and addendums should be used for pharmacy prior authorization requests for the medications below for clients enrolled in either fee-for-service Medicaid or the Children With Special Health Care Needs (CSHCN) Services Program.

Fee-For-Service Medicaid Criteria

Xenical® (orlistat)

Enzymes

Synagis® (palivizumab) 

  • VDP Approval Form (PDF)
  • Texas standard prior authorization form + synagis addendum (PDF)

CSHCN Criteria