Prescribing providers submit the following forms to request prior authorization for clients enrolled in the CSHCN Services Program. Refer to each form's instruction page for requirements and submission instructions. Refer to the CSHCN Services Program - Prior Authorization Contacts section for program contact information.
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Providers must submit each request below with the Texas Department of Insurance (TDI) Texas Standard Prior Authorization Request Form for Prescription Drug Benefits. Failure to submit both forms will result in authorization delay or denial.
- Standard Prior Authorization Request (TDI Form NOFR002)
- txvendordrug.com/sites/default/files/docs/cshcn-standard-pa-form.pdf
Cystic Fibrosis Treatment Agents
- Refer to the Cystic Fibrosis Treatment Agents section for more information.
- Cystic Fibrosis Treatment Agents Prior Authorization Request (CSHCN) (HHS Form 1143)
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1143-cystic-fibrosis-treatment-products-authorization-request-cshcn
Biosynthetic Growth Hormone Agents
- Refer to the Biosynthetic Growth Hormone Agents section for more information.
- Biosynthetic Growth Hormone Agents Prior Authorization Request (CSHCN) (HHS Form 1327)
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1327-growth-hormone-agents-standard-pa-addendum-cshcn
Synagis
- Refer to the Respiratory Syncytial Virus Treatment section for more information.
- HHS Form 1325
- hhs.texas.gov/regulations/forms/1000-1999/form-1325-synagis-prior-authorization-addendum-cshcn