Texas Medicaid Prior Authorization Form

Updated January 24, 2022

Texas Medicaid prior authorization form requests Medicaid coverage of a non-preferred drug in the State of Texas (a fillable PDF version of this form can be downloaded here). A non-preferred drug is a drug that does not appear on the State-approved Preferred Drug List. For more information, call one of the phone numbers provided below.

Texas Prior Authorization Call Center Phone Number – 1 (877) 728-3927

Texas Medicaid Phone Number – 1 (800) 925-9126

Preferred Drug List (PDL)

How to Write

Step 1 – Read through the first page of the document to ensure that you’re aware of how to correctly fill out the form.

Step 2 – Begin by entering who the form is being submitted to, their phone and fax numbers, and the date into the indicated fields of “Section I.”

Step 3 – In “Section II,” check the little box if you need this request to be expedited and, once printed, provide the prescriber’s signature.

Step 4 – In “Section III,” you will need to enter the following information into the indicated fields:

  • Patient’s full name
  • Patient’s date of birth
  • Patient’s gender
  • Patient’s complete address
  • Issuer name
  • Patient’s ID number
  • Group number, BIN number, PCN, and Rx ID number (if known)

Step 5 – Next, in “Section IV,” you will need to enter the prescriber’s name, NPI number, specialty, complete address, phone number, fax number, office contact name, and the contact’s phone number.

Step 6 – In “Section V,” enter the requested drug’s name, strength, route of administration, quantity, day’s supply, and expected therapy duration. Then, indicate whether this is a new therapy or a renewal, and (if applicable) enter the HCPCS code, NDC number, and dose per administration.

Step 7 – If the requested drug is a compound drug, in “Section VI” you will need to enter the compound drug name, as well as the name, NDC number, and quantity of each ingredient.

Step 8 – If you are requesting a prescription device, you will need to supply the device name, the expected duration of use, and its HCPCS code (if applicable) in “Section VII.”

Step 9 – Next, in “Section VIII,” you must enter the patient’s related diagnosis, as well as its ICD version and ICD code. Below that, enter the name, strength, frequency, dates of therapy, and reason for failure for any other drugs the patient has taken in treatment of the related diagnosis. If known or applicable, enter the patient’s drug allergies, height, and weight into the indicated fields.

Step 10 – You may either include supporting medical documentation as an attachment to the form, or you may list relevant lab results below the heading “Relevant laboratory values and dates.” If you are writing these results on the form, provide the date, type of test, and resulting value of each test into the indicated spaces.

Step 11 – Finally, in “Section IX” you are required to provide a written justification for requesting this particular drug instead of a drug from the PDL.

Step 12 – Print the document, provide the necessary signature, and send it to the correct directory by either fax or mail.