Prior Authorization Forms
Prior authorization forms and addendums are completed and submitted by the prescribing physician to the Vendor Drug Program.
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
- Cystic fibrosis treatment products
- Cayston® (aztreonam for inhalation solution)
- Kalydeco® (ivacaftor)
- Pulmozyme® (dornase alfa)
- Tobi® (tobramycin inhalation powder)
- Growth hormone products
- Family Planning / HIV Products / Pulmonary hypertension drugs
- Pharmacy staff should obtain a letter of medical necessity from the prescribing physician on office stationery and fax to the CSHCN Services Program at 512-776-7162. For more information call CSHCN at 1-800-252-8023
- Synagis® (palivizumab)