Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.
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Synagis Standard Addendum (Texas) Prior Authorization Form - Community Plan
Last Published 10.08.2019
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Actemra (Texas) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Aliskiren Agents 150 mg (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Aliskiren Agents 300 mg (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Androgenic Agents (Texas) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Antihistamines, First Generation (Texas) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Antihistamines, Minimally Sedating (Texas) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Antipsychotics (Texas) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Arcalyst (Texas) Prior Authorization Form - Community Plan
Last Published 04.29.2018
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Austedo / Xenazine (Texas) Prior Authorization Form - Community Plan
Last Published 06.04.2019
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Buprenorphine (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Buprenorphine-Naloxone (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Carisoprodol Containing Agents (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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CGRP Antagonists (Texas) Prior Authorization Form - Community Plan
Last Published 01.30.2019
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Cimzia (Texas) Prior Authorization Form - Community Plan
Last Published 03.12.2019
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Cosentyx (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Cough and Cold, Opiate Combination (Texas) Prior Authorization Form - Community Plan
Last Published 10.23.2018
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Cymbalta (Texas) Prior Authorization Form - Community Plan
Last Published 09.07.2018
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Cystic Fibrosis Agents, Oral (Texas) Prior Authorization Form - Community Plan
Last Published 03.05.2019
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Diclofenac 1.5% and 2% Solution (Texas) Prior Authorization Form - Community Plan
Last Published 09.07.2018
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Diclofenac 3% Gel (Texas) Prior Authorization Form - Community Plan
Last Published 09.07.2018
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DPP-4 Inhibitors (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Dupixent (Texas) Prior Authorization Form - Community Plan
Last Published 05.01.2019
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Emflaza (Texas) Prior Authorization Form - Community Plan
Last Published 07.02.2019
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Enbrel (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Erythropoiesis Stimulating Agents: Aranesp (Texas) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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Erythropoiesis Stimulating Agents: Epogen or Procrit (Texas) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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Eucrisa Ointment (Texas) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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General Non-Preferred Medication (Texas) Prior Authorization Form - Community Plan
Last Published 07.25.2018
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GI Motility Agents, Chronic (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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GLP-1 Receptor Agonists (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Gralise (Texas) Prior Authorization Form - Community Plan
Last Published 03.13.2019
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Hereditary Angioedema (HAE) Agents (Texas) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Horizant ER (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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HP Acthar Gel (Texas) Prior Authorization Form - Community Plan
Last Published 01.25.2019
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Humira (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Ilaris (Texas) Prior Authorization Form - Community Plan
Last Published 10.10.2018
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Imiquimod (Texas) Prior Authorization Form - Community Plan
Last Published 02.19.2019
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Ingrezza (Texas) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Insulin Pen Needles and Syringes (Texas) Prior Authorization Form - Community Plan
Last Published 12.27.2018
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Keveyis (Texas) Prior Authorization Form - Community Plan
Last Published 12.31.2018
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Kevzara (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Kineret (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Lidocaine Patches (Texas) Prior Authorization Form - Community Plan
Last Published 01.03.2019
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Lyrica (Texas) Prior Authorization Form - Community Plan
Last Published 09.07.2018
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Makena (Texas) Prior Authorization Form - Community Plan
Last Published 08.06.2019
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Nuvigil (Texas) Prior Authorization Form - Community Plan
Last Published 01.25.2019
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Olumiant (Texas) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Opioid Products (Texas) Prior Authorization Form - Community Plan
Last Published 02.04.2019
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Orencia (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Orilissa (Texas) Prior Authorization Form - Community Plan
Last Published 04.29.2019
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Otezla (Texas) Prior Authorization Form - Community Plan
Last Published 10.04.2018
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Oxycodone Extended Release Agents, Low Dose (Texas) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Oxycodone Extended-Release Agents, High Dose (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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PCSK9 Inhibitors (Texas) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Phosphate Binders (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Proton Pump Inhibitors (PPIs) (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Provigil (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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Pulmonary Arterial Hypertension (Texas) Prior Authorization Form - Community Plan
Last Published 12.28.2018
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Ranexa (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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SGLT-2 Inhibitors (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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Sildenafil (Texas) Prior Authorization Form - Community Plan
Last Published 01.07.2019
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Siliq (Texas) Prior Authorization Form - Community Plan
Last Published 03.12.2019
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Simponi (Texas) Prior Authorization Form - Community Plan
Last Published 10.03.2018
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Stelara (Texas) Prior Authorization Form - Community Plan
Last Published 10.04.2018
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Stimulants (Texas) Prior Authorization Form - Community Plan
Last Published 01.11.2019
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Symdeko (Texas) Prior Authorization Form - Community Plan
Last Published 10.12.2018
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Symlin (Texas) Prior Authorization Form - Community Plan
Last Published 01.29.2019
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Synagis (Texas) Prior Authorization Form - Community Plan
Last Published 10.08.2019
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Taltz (Texas) Prior Authorization Form - Community Plan
Last Published 05.06.2019
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Thiazolidinediones (Texas) Prior Authorization Form - Community Plan
Last Published 03.11.2019
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Topical Immunomodulators [Elidel, Protopic] (Texas) Prior Authorization Form - Community Plan
Last Published 10.16.2018
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Tremfya (Texas) Prior Authorization Form - Community Plan
Last Published 03.12.2019
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Xeljanz (Texas) Prior Authorization Form - Community Plan
Last Published 03.12.2019
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Xenical (Texas) Prior Authorization Form - Community Plan
Last Published 05.01.2019
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Xifaxan (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019
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Xyrem (Texas) Prior Authorization Form - Community Plan
Last Published 04.16.2019
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Zelboraf (Texas) Prior Authorization Form - Community Plan
Last Published 01.28.2019