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Help areas such as this are found throughout the application. These areas aim to simplify the usage of the various pages.

Emflaza Prior Authorization Form

Hepatitis C - Initial Request Form

Hepatitis C - Refill Request Form

Makena Prior Authorization Form

PCSK9 Inhibitors Prior Authorization Form

Synagis Prior Authorization Form

Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

Cystic Fibrosis Addendum

Hepatitis C Addendum

Increlex Addendum

Makena Addendum

Oxycontin Addendum

PCSK9 Inhibitors Addendum

Phosphate Binders Addendum (non-preferred agents only)

Synagis Addendum to Standard PA Form

Preferred Drug List (PDL)

PDL Criteria Guide

For assistance with Fee For Service
PA requests only, call the Prior
Authorization Call Center
at 1-877-PA-TEXAS (1-877-728-3927)

Patient member of Medicaid Managed Care Organization (MCO)?

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