Prior Authorization Requests (CSHCN Services Program)
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.
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.
Each form has a related drug or drug class-related section in the Formulary Coverage section of this manual.
| Form Name | Form Number |
|---|---|
| Cystic Fibrosis Treatment Products Authorization Request (PDF) | HHS Form 1143 |
| Biosynthetic Growth Hormone Agents Prior Authorization Request (PDF) | HHS Form 1327 |
| Synagis Prior Authorization Prior Authorization Request (PDF) | HHS Form 1325 |
| Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) | TDI Form NOFR002 |