Prescribing providers use these forms to request prior authorization for clients enrolled in Medicaid fee-for-service. Refer to each form's instruction page, linked below, for submission instructions.
Refer to the Medicaid Clinical Prior Authorization section to learn more.
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)
Cystic Fibrosis Treatment Agents
- Refer to the Cystic Fibrosis Treatment Agents section for more information.
- Cystic Fibrosis Treatment Agents Prior Authorization Request (Medicaid) (HHS Form 1338)
- Refer to the Emflaza section for more information.
- HHS Form 1347
- Refer to the Increlex section for more information.
- HHS Form 1357
- Refer to the Oxycontin section for more information.
- HHS Form 1353
PCSK9 Inhibitor Agents
- Refer to the Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Agents section for more information.
- HHS Form 1355
Phosphate Binder Agents
- Refer to the Phosphate Binder Agents section for more information.
- HHS Form 1348
- Refer to the Respiratory Syncytial Virus Treatment section for more information.
- HHS Form 1321
- Refer to the Xyrem section for more information.
- HHS Form 1356