The Texas Department of Insurance requires Medicaid to publish the Texas Standardized Prior Authorization Request Form for Health Care Services (TDI Form NOFR002) for prescribing providers as of September 1, 2015.  Refer to 1 TAC Section 19.1820 (Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use) on the VDP website Rules and Statutes page (txvendordrug.com/about/rules). 

Providers use this form to request prior authorization by fax or mail.  Some medications will require providers to submit an addendum form to capture additional information.  Failure to submit both the Standardized Prior Authorization Request and addendum may result in an authorization denial.

Refer to the Medicaid Fee-for-service Prior Authorization Requests section for a list of addendum forms.

Refer to the CSHCN Services Program Prior Authorization Requests section for a list of addendum forms.