Obtaining Prior Authorization

In certain instances, pharmacy and medical claims data will be available to indicate when a person has met the prior authorization criteria. In those cases, the prescription is authorized automatically at the point of sale without any notification to prescribing provider or dispensing pharmacy.

If supporting claims data is not available to the automated prior authorization system, the claim will reject with NCPDP error code 75 ("Prior Authorization Required"). The pharmacy should notify the prescribing providers or their representatives about the prior authorization requirement so they can request authorization. Pharmacy providers cannot request authorization. A decision from the prior authorization authority to approve or deny the request is made within 24 hours of the initial request.

Refer to the contact section for FFS Medicaid Clinical Prior Authorization contact information.

Refer to the contact section for FFS Medicaid Non-preferred Prior Authorization contact information.

Refer to the contact section for MCO Prior Authorization contact information.

The Texas Department of Insurance requires HHSC 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 TAC Section 19.1820 (Subchapter S: Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use).

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.