Prior Authorization Requests (Medicaid fee-for-service)
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.
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 |
|---|---|
| Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) | TDI Form NOFR002 |
| Cystic Fibrosis Treatment Agents Authorization Request (PDF) | HHS Form 1338 |
| Increlex Authorization Request (PDF) | HHS Form 1357 |
| OxyContin Authorization Request (PDF) | HHS Form 1353 |
| PCSK9 Inhibitor Agents Authorization Request (PDF) | HHS Form 1355 |
| Phosphate Binder Agents Authorization Request (PDF) | HHS Form 1348 |
| Synagis Prior Authorization Prior Authorization Request (PDF) | HHS Form 1321 |
| Xyrem Authorization Request (PDF) | HHS Form 1356 |