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. 

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.

Cystic Fibrosis Treatment Agents

Emflaza

Increlex

OxyContin

PCSK9 Inhibitor Agents

Phosphate Binder Agents

Synagis

Xyrem