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
Providers must submit each request below with the Texas Department of Insurance (TDI) Standard Prior Authorization Request. 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/medicaid-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 (Medicaid) (HHS Form 1338)
- )hhs.texas.gov/laws-regulations/forms/1000-1999/form-1338-cystic-fibrosis-agents-kalydecoorkambisymdeko-medicaid-standard-pa-addendum
Emflaza
- HHS Form 1347
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1347-emflaza-authorization-request-medicaid
Increlex
- HHS Form 1357
- hhs.texas.gov/regulations/forms/1000-1999/form-1357-increlex-standard-pa-addendum-medicaid
Makena
- HHS Form 1346
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1346-makena-standard-pa-addendum-fee-service-medicaid
OxyContin
- HHS Form 1353
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1353-oxycontin-standard-pa-addendum-medicaid
PCSK9 Inhibitor Agents
- HHS Form 1355
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1355-pcsk9-inhibitors-standard-pa-addendum-medicaid-fee-service
Phosphate Binder Agents
- HHS Form 1348
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1348-phosphate-binders-standard-pa-addendum-medicaid
Synagis
- HHS Form 1321
- hhs.texas.gov/laws-regulations/forms/1000-1999/form-1321-synagis-standard-prior-authorization-addendum-medicaid