Requests for pharmacy prior authorization may be submitted via fax or mail using the Texas Standard Prior Authorization Form. Prescribing providers may continue, and are encouraged, to request prior authorization for traditional Medicaid patients by calling the Texas Prior Authorization Call Center. Please visit PAxpress for forms and addendums for clinical prior authorization requests.
Pharmacy prior authorization services are administered by the MCO and call center phone numbers will vary between each MCO. Download the Prescriber Assistance Chart (PDF) for contact information and for the Texas Standard Prior Authorization Forms and instructions for people enrolled in Medicaid managed care.
Internal Prior Authorization Forms
The following prior authorizations are reviewed internally by the Vendor Drug Program. Providers and pharmacy staff should use either form #1 or #2 to and submit the completed form to VDP. All submissions must be from the prescribing physician..
- Enzyme Replacement Therapy
- Xenical (orlistat)
- Medicaid Xenical Clinic Prior Authorization (HHS Form 1331)
- Medicaid Xenical Clinic Prior Authorization Addendum (HHS Form 1333)
- This addendum must be accompanied by the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial.