Medicaid Managed Care

Prescribing providers and pharmacy staff should contact the appropriate health plan for prior authorization requirements using the contact information on the Prescriber MCO Assistance Chart (PDF).

Traditional Medicaid

Use either form 1033 or 1321 and submit to the Texas Prior Authorization Call Center.

Form Name Form Number
Medicaid Synagis Prior Authorization Request HHS 1033
Medicaid Synagis Prior Authorization Request Addendum HHS 1321

CSHCN Services Program

Use either form 1055 or 1325 and submit to the CSHCN Services Program.

Form Name Form Number
CSHCN Synagis Authorization Request HHS 1055
CSHCN Synagis Authorization Request Addendum HHS 1325