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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.
Forms (Fee-For-Service Medicaid Only)
Emflaza Prior Authorization Form
Hepatitis C - Initial Request Form
Hepatitis C - Refill Request Form
Makena Prior Authorization Form
PCSK9 Inhibitors Prior Authorization Form
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Cystic Fibrosis Addendum
Hepatitis C Addendum (link to 2017 version)
Hepatitis C Addendum (Effective March 1, 2021)
Increlex Addendum
Makena Addendum
Oxycontin Addendum
PCSK9 Inhibitor Addendum
Phosphate Binders Addendum (non-preferred agents only)
Synagis Addendum to Standard PA Fom
Xyrem Addendum
PDL
Preferred Drug List (PDL)
PDL Criteria Guide
TX-Phone-Number
For assistance with Fee For Service
PA requests only, call the Prior
Authorization Call Center
at 1-877-PA-TEXAS (1-877-728-3927)
Managed-Care
Patient member of Medicaid Managed Care Organization (MCO)?
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