Managed Care (Medicaid and CHIP)
- Prescribing providers and pharmacy staff should contact each MCO for prior authorization requirements using the contact information on the Prescriber MCO Assistance Chart (PDF).
Complete both forms. Refer to form for requirements and submission instructions. Failure to submit both forms will result in authorization denial. Submit to the Texas Prior Authorization Call Center.
|Form Name||Form Number|
|Standard Prior Authorization Request (PDF)||TDI NOFR002|
CSHCN Services Program
Refer to the list of CSHCN Prior Authorization Requests (forms) in the Pharmacy Provider Procedure Manual.