Instructions

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 MCO 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.   All submissions must be from the prescribing physician, and sent to VDP.

Form Name Form Number
Enzyme Replacement Therapy Products Request HHS 1328
Medicaid Xenical Clinic Prior Authorization  HHS 1331

Texas Standard Prior Authorization Form Addendum

The following Standard Prior Authorization Form Addendum and instructions must be accompanied by the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial. All submissions must be from the prescribing provider.

Form Name Form Number
Enzyme Replacement Therapy Products Request (PDF) TDI NOFR002
Medicaid Xenical Clinic Prior Authorization Addendum HHS 1333